Provider Demographics
NPI:1114045440
Name:JANG, EDWARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:JANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 APPIAN WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:PINOLE
Mailing Address - State:CA
Mailing Address - Zip Code:94564-2574
Mailing Address - Country:US
Mailing Address - Phone:510-724-8555
Mailing Address - Fax:510-724-3555
Practice Address - Street 1:2000 APPIAN WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:PINOLE
Practice Address - State:CA
Practice Address - Zip Code:94564-2574
Practice Address - Country:US
Practice Address - Phone:510-724-8555
Practice Address - Fax:510-724-3555
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38059122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist