Provider Demographics
NPI:1154490639
Name:JEON, DANNY (DMD)
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 NORTHLAKE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084
Mailing Address - Country:US
Mailing Address - Phone:678-937-9601
Mailing Address - Fax:678-937-9602
Practice Address - Street 1:2258 NORTHLAKE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084
Practice Address - Country:US
Practice Address - Phone:678-937-9601
Practice Address - Fax:678-937-9602
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0131961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA733999822AMedicaid