Healthcare Provider Details

I. General information

NPI: 1750483673
Provider Name (Legal Business Name): MS. JACQUELYN HOANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14912 FALCONWOOD DR
BURTONSVILLE MD
20866-1349
US

IV. Provider business mailing address

14912 FALCONWOOD DR
BURTONSVILLE MD
20866-1349
US

V. Phone/Fax

Practice location:
  • Phone: 240-593-6329
  • Fax: 703-877-2100
Mailing address:
  • Phone: 240-593-6329
  • Fax: 703-877-2100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12018
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: