Provider Demographics
NPI:1598768129
Name:CHIANG, JONATHAN Y (DDS)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:Y
Last Name:CHIANG
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 1:6336 BOBCAT HILL PL. NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-8053
Mailing Address - Country:US
Mailing Address - Phone:808-554-1566
Mailing Address - Fax:
Practice Address - Street 1:9169 COORS RD. NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87193
Practice Address - Country:US
Practice Address - Phone:505-733-8440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-026320122300000X
UT5538443-9921/8903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45076880Medicaid