Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 0401415189 | VA |
N | 1223P0700X | Prosthodontist | R558 | MN |
NPI | 1114364551 |
---|---|
Provider Name | Dr. Jason P. Kiangsoontra |
First Address | Fairfax, VA 22031-1863 |
Second Address | Gainesville, VA 20155-3831 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/05/2013 |
Last Update Date | 08/12/2018 |