Provider Demographics
NPI:1528463825
Name:CHIANG, JACK (DDS)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:CHIANG
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 1:840 SE BISHOP BLVD
Mailing Address - Street 2:STE 204
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5502
Mailing Address - Country:US
Mailing Address - Phone:509-332-3213
Mailing Address - Fax:509-332-6262
Practice Address - Street 1:840 SE BISHOP BLVD
Practice Address - Street 2:STE 204
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5502
Practice Address - Country:US
Practice Address - Phone:509-332-3213
Practice Address - Fax:509-332-6262
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA87591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1019711Medicaid