Healthcare Provider Details

I. General information

NPI: 1477006799
Provider Name (Legal Business Name): JIC DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37B GARRETT RD
UPPER DARBY PA
19082-2302
US

IV. Provider business mailing address

37B GARRETT RD
UPPER DARBY PA
19082-2302
US

V. Phone/Fax

Practice location:
  • Phone: 610-352-4091
  • Fax:
Mailing address:
  • Phone: 610-352-4091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS030832L
License Number StatePA

VIII. Authorized Official

Name: DR. YOUNG SOO JANG
Title or Position: OWNER
Credential: DMD
Phone: 267-632-5774