Active NPI
Kyung Nam, DDS
- Periodontics
- San Jose, CA
National Provider Identifier
1548934615
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- 106717
- Practice address
- 6701 Edgemoor Way
San Jose, CA 95129-2933 - Phone
- (408) 464-1912
- NPI assigned
- Aug 3, 2021
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | 106717 | CA | Primary |
Addresses
Primary practice location
6701 Edgemoor Way
San Jose, CA 95129-2933
Mailing address
6701 Edgemoor Way
San Jose, CA 95129-2933
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Opted out of Medicare
- Yes, effective Oct 4, 2021 through Oct 4, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 106717 | CA | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1627948800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1627948800000",
"number": "1548934615",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "6701 EDGEMOOR WAY",
"city": "SAN JOSE",
"state": "CA",
"postal_code": "951292933"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "6701 EDGEMOOR WAY",
"city": "SAN JOSE",
"state": "CA",
"postal_code": "951292933",
"telephone_number": "408-464-1912"
}
],
"practiceLocations": [],
"basic": {
"last_name": "NAM",
"first_name": "KYUNG",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2021-08-03",
"last_updated": "2021-08-03",
"certification_date": "2021-08-03",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "CA",
"license": "106717",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in San Jose, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 3, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.