1790137545 NPI number — DR. ADRIANNA MIRIM JANG DMD

Table of content: DR. ADRIANNA MIRIM JANG DMD (NPI 1790137545)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790137545 NPI number — DR. ADRIANNA MIRIM JANG DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JANG
Provider First Name:
ADRIANNA
Provider Middle Name:
MIRIM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JANG
Provider Other First Name:
MI
Provider Other Middle Name:
RIM
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790137545
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10288 77TH ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PLEASANT PRAIRIE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53158-1133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-697-4222
Provider Business Mailing Address Fax Number:
262-697-4370

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10288 77TH ST
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
PLEASANT PRAIRIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53158-1133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-697-4222
Provider Business Practice Location Address Fax Number:
262-697-4370
Provider Enumeration Date:
07/05/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1001392 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)