Provider Demographics
NPI:1194023317
Name:JEONG, GARY G (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:JEONG
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 1:362 JOAQUIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4712
Mailing Address - Country:US
Mailing Address - Phone:510-483-4543
Mailing Address - Fax:510-483-2282
Practice Address - Street 1:362 JOAQUIN AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4712
Practice Address - Country:US
Practice Address - Phone:510-483-4543
Practice Address - Fax:510-483-2282
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA221571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice