Basic Information
| Provider Information | |||||||||
| NPI: | 1316366719 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANG | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PAPPAS | ||||||||
| OtherFirstName: | KIMBERLY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 50 HAVEN AVE | ||||||||
| Address2: | MAILBOX B9 | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100322652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162151175 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16111 PLUMMER ST | ||||||||
| Address2: | |||||||||
| City: | NORTH HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913432036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188917711 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2014 | ||||||||
| LastUpdateDate: | 04/14/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | CA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.