Basic Information
| Provider Information | |||||||||
| NPI: | 1285180638 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JANG | ||||||||
| FirstName: | JAEWOONG | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11050 LEE HWY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220305014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035206376 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11050 LEE HWY | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220305014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035206376 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2016 | ||||||||
| LastUpdateDate: | 07/22/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DEN10001656 | DC | N | Dental Providers | Dentist | 122300000X | 0401415368 | VA | Y | Dental Providers | Dentist |
No ID Information.