Provider Demographics
NPI:1952314155
Name:CHONG, JAE MIN (DMD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:MIN
Last Name:CHONG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14215F CENTREVILLE SQ
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-2301
Mailing Address - Country:US
Mailing Address - Phone:703-825-1191
Mailing Address - Fax:703-825-7356
Practice Address - Street 1:14215F CENTREVILLE SQ
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-2301
Practice Address - Country:US
Practice Address - Phone:703-825-1191
Practice Address - Fax:703-825-7356
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice