Provider Demographics
NPI:1700363843
Name:YUAN, JINGQIAN
Entity Type:Individual
Prefix:
First Name:JINGQIAN
Middle Name:
Last Name:YUAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N G ST
Mailing Address - Street 2:APT #225
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98403
Mailing Address - Country:US
Mailing Address - Phone:248-918-9842
Mailing Address - Fax:
Practice Address - Street 1:8012 112TH STREET CT E STE 320
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-7856
Practice Address - Country:US
Practice Address - Phone:248-918-9842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-22
Last Update Date:2018-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608627361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice