Provider Demographics
NPI:1912967431
Name:JANG, PETER SUCHOL (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:SUCHOL
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 1:3161 HIGHWAY 64
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EADS
Mailing Address - State:TN
Mailing Address - Zip Code:38028-3021
Mailing Address - Country:US
Mailing Address - Phone:901-813-8476
Mailing Address - Fax:901-813-8479
Practice Address - Street 1:3161 HIGHWAY 64
Practice Address - Street 2:SUITE 400
Practice Address - City:EADS
Practice Address - State:TN
Practice Address - Zip Code:38028-3021
Practice Address - Country:US
Practice Address - Phone:901-813-8476
Practice Address - Fax:901-813-8479
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS 8164122300000X, 1223X0400X
AR36011223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440084Medicaid