Provider Demographics
NPI:1013590025
Name:BOM JEON DENTAL CORP
Entity Type:Organization
Organization Name:BOM JEON DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOM
Authorized Official - Middle Name:
Authorized Official - Last Name:JEON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-485-9999
Mailing Address - Street 1:1401 S BROOKHURST RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4492
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 S BROOKHURST RD STE 104
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4492
Practice Address - Country:US
Practice Address - Phone:714-879-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental