Provider Demographics
NPI:1083039168
Name:CHONG, JASON SUB (DMD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:SUB
Last Name:CHONG
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 1:271 FT RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:GOODFELLOW AIR FORCE BASE
Mailing Address - State:TX
Mailing Address - Zip Code:76908-5638
Mailing Address - Country:US
Mailing Address - Phone:325-654-3050
Mailing Address - Fax:
Practice Address - Street 1:271 FT RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:GOODFELLOW AIR FORCE BASE
Practice Address - State:TX
Practice Address - Zip Code:76908
Practice Address - Country:US
Practice Address - Phone:325-654-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-25
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040168122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist