Provider Demographics
NPI:1962269324
Name:JANG, GYUHA
Entity type:Individual
Prefix:
First Name:GYUHA
Middle Name:
Last Name:JANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26460 FIELDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-2153
Mailing Address - Country:US
Mailing Address - Phone:248-595-9767
Mailing Address - Fax:
Practice Address - Street 1:188 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5888
Practice Address - Country:US
Practice Address - Phone:617-432-1434
Practice Address - Fax:617-432-4258
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN10000148122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist