Provider Demographics
NPI:1033895453
Name:BANG, JEFF (DMD)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:BANG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 PARKER RD SE APT 1205
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-6301
Mailing Address - Country:US
Mailing Address - Phone:678-559-4911
Mailing Address - Fax:
Practice Address - Street 1:421 IL-173
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:IL
Practice Address - Zip Code:60002
Practice Address - Country:US
Practice Address - Phone:224-788-7348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.034339122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist