Peter Suchol Jang, D.D.S.
Individual provider Active NPI Orthodontics and Dentofacial Orthopedics Dentistry · Eads, TN
NPI 1912967431 · NPPES record last updated May 11, 2011
Key facts
- NPI
- 1912967431
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Orthodontics and Dentofacial Orthopedics Dentistry 1223X0400X
- License
- DS 8164 (TN)
- Practice address
- 3161 Highway 64
Suite 400
Eads, TN 38028-3021 - Phone
- (901) 813-8476
- Fax
- (901) 813-8479
- NPI assigned
- Mar 27, 2006
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DS 8164 | TN | MD | Orthodontics and Dentofacial Orthopedic Dentist |
| 3601 | AR | MD | Physical Therapist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DS 8164 | TN | |
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | DS 8164 | TN | Yes |
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | 3601 | AR |
Addresses
Primary practice location
3161 Highway 64
Suite 400
Eads, TN 38028-3021
Mailing address
3161 Highway 64
Suite 400
Eads, TN 38028-3021
Phone (901) 813-8476
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 5440084 | Medicaid | TN |
Other providers in Eads, TN
- Paige Gassmann
- Donna V Goings
- Paul M Hambrick
- Garry Lynn Huff
- Insight Behavioral Health Services, PLLC
- Patricia Rena Jones-Purdy
- Emily Kautzman
- Diane Marie Lafferty
- Lighthouse Family Dentistry
- M-Power, Inc.
All providers in Eads, TN · Orthodontics and Dentofacial Orthopedics Dentistry in Tennessee
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on May 11, 2011. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.