Provider Demographics
NPI:1760949671
Name:AN, JAE
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:AN
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 1:65 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2474
Mailing Address - Country:US
Mailing Address - Phone:908-469-9100
Mailing Address - Fax:
Practice Address - Street 1:65 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2474
Practice Address - Country:US
Practice Address - Phone:908-469-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-27
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028114001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice