1699897223 NPI number — TOM KEH JENS WANG A PROFESSIONAL DENTAL CORP

Table of content: DR. JON LEO KONZEN M.D. (NPI 1013202340)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699897223 NPI number — TOM KEH JENS WANG A PROFESSIONAL DENTAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOM KEH JENS WANG A PROFESSIONAL DENTAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699897223
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1408 S SAN GABRIEL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN GABRIEL
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91776-3603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-572-7211
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 S SAN GABRIEL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN GABRIEL
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91776-3603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-572-7211
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WANG
Authorized Official First Name:
TOM
Authorized Official Middle Name:
K J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
626-572-7211

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  32223 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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