Provider Demographics
NPI:1871107201
Name:HOANG, JONATHAN VAN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:VAN
Last Name:HOANG
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 1:13932 LAUREL ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-1433
Mailing Address - Country:US
Mailing Address - Phone:714-478-5274
Mailing Address - Fax:
Practice Address - Street 1:49271 GRAPEFRUIT BLVD STE 1
Practice Address - Street 2:
Practice Address - City:COACHELLA
Practice Address - State:CA
Practice Address - Zip Code:92236-1485
Practice Address - Country:US
Practice Address - Phone:760-398-3636
Practice Address - Fax:760-398-2220
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105394122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist