Provider Demographics
NPI:1194275826
Name:JANG, MIRA (DDS)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:JANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4212 TEMECULA CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75070-6808
Mailing Address - Country:US
Mailing Address - Phone:214-909-2312
Mailing Address - Fax:
Practice Address - Street 1:225 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76164-7205
Practice Address - Country:US
Practice Address - Phone:817-624-0044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32472122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist