Organization
DEEP ROOTS PERIODONTICS PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TAEHEON KANG D.D.S., M.S. (PERIODONTIS)
(954) 536-1111
Entity
Organization
Contact information
Practice address
11130 FAIRFAX BLVD, SUITE 100, FAIRFAX, VA 22030-5035
(954) 536-1111
Mailing address
11130 FAIRFAX BLVD, SUITE 100, FAIRFAX, VA 22030-5035
(954) 536-1111
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
0401-413327
VA
Other
Enumeration date
06/25/2012
Last updated
06/25/2012
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