=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194882001
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NATHAN CHONG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 03/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9428 MAIN ST
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-323-5296
-----------------------------------------------------
Fax | 703-503-3024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9428 MAIN ST
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22031-4032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-323-5296
-----------------------------------------------------
Fax | 703-503-3024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 0401410829
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 56152
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------