Provider Demographics
NPI:1033295753
Name:JEON, PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:
Last Name:JEON
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 1:1432 PACES COMMONS DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1725
Mailing Address - Country:US
Mailing Address - Phone:678-557-0500
Mailing Address - Fax:
Practice Address - Street 1:1756 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3277
Practice Address - Country:US
Practice Address - Phone:678-904-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0128651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA250276271CMedicaid
GA250276271HMedicaid