Provider Demographics
NPI:1386923811
Name:DANG, JACKILYN (DMD)
Entity type:Individual
Prefix:DR
First Name:JACKILYN
Middle Name:
Last Name:DANG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 SW GREEN OAKS BLVD
Mailing Address - Street 2:STE 101
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-4130
Mailing Address - Country:US
Mailing Address - Phone:817-789-4488
Mailing Address - Fax:
Practice Address - Street 1:3851 SW GREEN OAKS BLVD
Practice Address - Street 2:#100
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-4130
Practice Address - Country:US
Practice Address - Phone:817-789-4488
Practice Address - Fax:817-541-4471
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272311223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX282677802Medicaid
TX800851489Medicaid