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General NPI Number Information
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NPI Number | 1255822961
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Entity Type | Individual
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Provider Name | JACKIE HWANG
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Gender | Female
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Dates
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Enumeration Date | 05/29/2018
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Last Update Date | 08/16/2020
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Provider Practice Location Address
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Address Line | 3020 OLD CENTRE RD
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City | PORTAGE
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State | MI
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Zip | 49024-4883
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Country | US
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Telephone | 269-323-8016
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Fax |
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Provider Business Mailing Address
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Address Line | 8397 WARBLER DR
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City | KALAMAZOO
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State | MI
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Zip | 49009-4549
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Country | US
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Telephone | 281-300-5279
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2901600444
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License Number State | MI
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