Provider Demographics
NPI:1538833975
Name:LIAO, JASON SHAN-CHONG (DMD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SHAN-CHONG
Last Name:LIAO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4640 73RD ST E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34203-7999
Mailing Address - Country:US
Mailing Address - Phone:732-543-6335
Mailing Address - Fax:
Practice Address - Street 1:BRIAN D. ALLGOOD ARMY COMMUNITY HOSPITAL (BDAACH)
Practice Address - Street 2:UNIT 15245
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271-5245
Practice Address - Country:US
Practice Address - Phone:315-737-2028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist