Provider Demographics
NPI:1104311851
Name:HA, JAE HEUNG (DDS)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:HEUNG
Last Name:HA
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 1:3637 NW BYRON ST
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-9971
Mailing Address - Country:US
Mailing Address - Phone:360-692-9560
Mailing Address - Fax:
Practice Address - Street 1:3637 NW BYRON ST
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9971
Practice Address - Country:US
Practice Address - Phone:360-692-9560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60852932122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist