Provider Demographics
NPI:1114364551
Name:KIANGSOONTRA, JASON P (DDS, MS, FACP)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:P
Last Name:KIANGSOONTRA
Suffix:
Gender:M
Credentials:DDS, MS, FACP
Other - Prefix:DR
Other - First Name:JASON
Other - Middle Name:
Other - Last Name:KIANGSOONTRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS, FACP
Mailing Address - Street 1:3148 GOLDENWAVE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-1863
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7521 VIRGINIA OAKS DR STE 230
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3831
Practice Address - Country:US
Practice Address - Phone:703-754-7151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2018-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR5581223P0700X
VA04014151891223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics