Provider Demographics
NPI:1407461825
Name:KIYOSHI, JANGSU (DDS)
Entity Type:Individual
Prefix:
First Name:JANGSU
Middle Name:
Last Name:KIYOSHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3006 MAHOGANY ST NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-5589
Mailing Address - Country:US
Mailing Address - Phone:253-306-6306
Mailing Address - Fax:
Practice Address - Street 1:3006 MAHOGANY ST NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-5589
Practice Address - Country:US
Practice Address - Phone:253-306-6306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE61085948122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist