Healthcare Provider Details

I. General information

NPI: 1578548681
Provider Name (Legal Business Name): JAE I HWANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2005
Last Update Date: 12/28/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2151 FOUNTAIN DR STE 206
SNELLVILLE GA
30078
US

IV. Provider business mailing address

2897 N DRUID HILLS ROAD #318
DECATUR GA
30033
US

V. Phone/Fax

Practice location:
  • Phone: 470-638-2086
  • Fax:
Mailing address:
  • Phone: 470-638-2086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN014506
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDE00007767
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: