Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | DN014085 | GA |
N | 213EG0000X | General Practice | DN014085 | GA |
N | 1223G0001X | General Practice | DS038623 | PA |
N | 213EG0000X | General Practice | DS038623 | PA |
Y | 1223P0221X | Pediatric Dentist | DN014085 | GA |
N | 1223P0221X | Pediatric Dentist | DS038623 | PA |
NPI | 1023337094 |
---|---|
Provider Name | Dr. Justin Weitseng Chong |
First Address | Atlanta, GA 30350-4023 |
Second Address | Milton, GA 30004-5147 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/05/2010 |
Last Update Date | 10/07/2020 |