Healthcare Provider Details

I. General information

NPI: 1578940904
Provider Name (Legal Business Name): JPC DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2015
Last Update Date: 05/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13075 HIGHWAY 9 N STE 110
MILTON GA
30004-5145
US

IV. Provider business mailing address

13075 HIGHWAY 9 N STE 110
MILTON GA
30004-5145
US

V. Phone/Fax

Practice location:
  • Phone: 404-512-9355
  • Fax:
Mailing address:
  • Phone: 404-512-9355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDN014085
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN013923
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JUSTIN CHONG
Title or Position: OWNER
Credential: D.M.D.
Phone: 404-512-9355