Healthcare Provider Details

I. General information

NPI: 1619057718
Provider Name (Legal Business Name): JANSEN G. WOO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43063 PEACOCK MARKET PLZ SUITE 125
SOUTH RIDING VA
20152-4444
US

IV. Provider business mailing address

43063 PEACOCK MARKET PLZ SUITE 125
SOUTH RIDING VA
20152-4444
US

V. Phone/Fax

Practice location:
  • Phone: 703-327-0327
  • Fax: 703-327-3887
Mailing address:
  • Phone: 703-327-0327
  • Fax: 703-327-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10655
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: