=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801212303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIAFENG GU DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2014
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 974 N 21ST ST # A-1
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 740-366-3309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 974 N 21ST ST # A-1
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43055-2990
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 30024012
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------