Healthcare Provider Details

I. General information

NPI: 1871107201
Provider Name (Legal Business Name): JONATHAN VAN HOANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49271 GRAPEFRUIT BLVD STE 1
COACHELLA CA
92236-1485
US

IV. Provider business mailing address

13932 LAUREL ST
SANTA ANA CA
92703-1433
US

V. Phone/Fax

Practice location:
  • Phone: 760-398-3636
  • Fax: 760-398-2220
Mailing address:
  • Phone: 714-478-5274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number105394
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number105394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: