Provider Demographics
NPI:1477006799
Name:JIC DENTAL CARE
Entity Type:Organization
Organization Name:JIC DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YOUNG
Authorized Official - Middle Name:SOO
Authorized Official - Last Name:JANG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-632-5774
Mailing Address - Street 1:37B GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:UPPER DARBY
Mailing Address - State:PA
Mailing Address - Zip Code:19082-2302
Mailing Address - Country:US
Mailing Address - Phone:610-352-4091
Mailing Address - Fax:
Practice Address - Street 1:37B GARRETT RD
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-2302
Practice Address - Country:US
Practice Address - Phone:610-352-4091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JANG'S DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS030832L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023390590001Medicaid