Provider Demographics
NPI:1780313262
Name:JANG, ETHAN JOUNGYUN (DDS)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:JOUNGYUN
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 1:1612 UNISON DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2832
Mailing Address - Country:US
Mailing Address - Phone:804-658-6541
Mailing Address - Fax:
Practice Address - Street 1:1612 UNISON DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2832
Practice Address - Country:US
Practice Address - Phone:804-658-6541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401418075122300000X
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist