Healthcare Provider Details

I. General information

NPI: 1114364551
Provider Name (Legal Business Name): JASON P. KIANGSOONTRA DDS, MS, FACP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JASON KIANGSOONTRA DDS, MS, FACP

II. Dates (important events)

Enumeration Date: 05/24/2013
Last Update Date: 12/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7521 VIRGINIA OAKS DR STE 230
GAINESVILLE VA
20155-3831
US

IV. Provider business mailing address

3148 GOLDENWAVE CT
FAIRFAX VA
22031-1863
US

V. Phone/Fax

Practice location:
  • Phone: 703-754-7151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberR558
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number0401415189
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: