Provider Demographics
NPI:1467599274
Name:JANG, EUN SUB (D D S)
Entity Type:Individual
Prefix:DR
First Name:EUN SUB
Middle Name:
Last Name:JANG
Suffix:
Gender:M
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7138 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4306
Mailing Address - Country:US
Mailing Address - Phone:707-823-5308
Mailing Address - Fax:707-823-5256
Practice Address - Street 1:7138 WILLOW ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4306
Practice Address - Country:US
Practice Address - Phone:707-823-5308
Practice Address - Fax:707-823-5256
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA484681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13-4242731OtherTAX ID NUMBER