Provider Demographics
NPI:1255462339
Name:JHANG, ALEXANDER KISAM (DDS)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:KISAM
Last Name:JHANG
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 1:4141 POPPLETON WAY
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1981
Mailing Address - Country:US
Mailing Address - Phone:916-205-7074
Mailing Address - Fax:916-944-4126
Practice Address - Street 1:4534 PRECISSI LN STE A
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6213
Practice Address - Country:US
Practice Address - Phone:209-957-8940
Practice Address - Fax:209-957-7990
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42664122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA013553OtherDELTA CARE PMI
CAG93605-01OtherDENTI-CAL PROVIDER NUMBER
CAB42664-02OtherHEALTHY FAMILY PROGRAM
CA42664OtherCALIFORNIA LICENSE