Healthcare Provider Details

I. General information

NPI: 1497120232
Provider Name (Legal Business Name): JP DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 WOODLAND ST SUITE 32
HARTFORD CT
06105-2372
US

IV. Provider business mailing address

19 WOODLAND ST SUITE 32
HARTFORD CT
06105-2372
US

V. Phone/Fax

Practice location:
  • Phone: 860-525-2366
  • Fax:
Mailing address:
  • Phone: 860-525-2366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number011523
License Number StateCT

VIII. Authorized Official

Name: JUYONG CHUNG
Title or Position: MANAGER
Credential: DMD
Phone: 574-309-1619