Provider Demographics
NPI:1598864464
Name:DUONG, JAKE H (DMD, PA)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:H
Last Name:DUONG
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 CYPRESS STATION DR
Mailing Address - Street 2:SUITE A1
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3054
Mailing Address - Country:US
Mailing Address - Phone:281-866-0049
Mailing Address - Fax:281-866-0134
Practice Address - Street 1:1125 CYPRESS STATION DR
Practice Address - Street 2:SUITE A1
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3054
Practice Address - Country:US
Practice Address - Phone:281-866-0049
Practice Address - Fax:281-866-0134
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX219281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166617411Medicaid