=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538956321
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JONATHAN HOANG DDS PROFESSIONAL DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 04/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20106 PIONEER BLVD STE A
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-7400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-926-6643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 20106 PIONEER BLVD STE A
-----------------------------------------------------
City | CERRITOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90703-7400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-926-6643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | COLLIN TSAI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-794-4279
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------