Provider Demographics
NPI:1629567284
Name:JANG, CALEB KYUNGSUP (DDS)
Entity Type:Individual
Prefix:DR
First Name:CALEB
Middle Name:KYUNGSUP
Last Name:JANG
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 1:4802 NASH DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-2530
Mailing Address - Country:US
Mailing Address - Phone:917-575-5127
Mailing Address - Fax:
Practice Address - Street 1:956 CHANDLER CT
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20602-2800
Practice Address - Country:US
Practice Address - Phone:301-705-9737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-08
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10018831223G0001X
VA04014164431223G0001X
MD172271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice