Provider Demographics
NPI:1164101945
Name:WIE, JONGBIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:JONGBIN
Middle Name:
Last Name:WIE
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 1:1425 RIVERSTONE PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5611
Mailing Address - Country:US
Mailing Address - Phone:954-952-2081
Mailing Address - Fax:
Practice Address - Street 1:1425 RIVERSTONE PKWY # 200
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-5611
Practice Address - Country:US
Practice Address - Phone:770-479-0600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1230981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice