=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215352182
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHUNG-AH JANG DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2014
-----------------------------------------------------
Last Update Date | 02/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1900 NE 162ND AVE D101
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98684
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-883-7866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18501 SE 42ND CIRCLE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98683
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | CHUNG-AH JANG
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 248-910-4830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DE60019072
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------