Provider Demographics
NPI:1255822961
Name:HWANG, JACKIE
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:
Last Name:HWANG
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 1:8397 WARBLER DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4549
Mailing Address - Country:US
Mailing Address - Phone:281-300-5279
Mailing Address - Fax:
Practice Address - Street 1:3020 OLD CENTRE RD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4883
Practice Address - Country:US
Practice Address - Phone:269-323-8016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-29
Last Update Date:2020-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016004441223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry