Provider Demographics
NPI:1033618640
Name:ANG, JONATHAN MATTHEW
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:MATTHEW
Last Name:ANG
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 1:7902 TYSONS ONE PL UNIT 2707
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-5240
Mailing Address - Country:US
Mailing Address - Phone:716-289-8654
Mailing Address - Fax:
Practice Address - Street 1:21 TOTMAN ST STE 201
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7564
Practice Address - Country:US
Practice Address - Phone:617-472-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18592611223P0221X
390200000X
NJ22DI027942001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program