Provider Demographics
NPI:1760820435
Name:AN, JAE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:
Last Name:AN
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 1:24812 NORTHERN BLVD
Mailing Address - Street 2:2F
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1206
Mailing Address - Country:US
Mailing Address - Phone:718-428-2663
Mailing Address - Fax:
Practice Address - Street 1:1540 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07424-1852
Practice Address - Country:US
Practice Address - Phone:973-812-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-04
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02532400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist