Provider Demographics
NPI:1215594346
Name:YOU, JAE YEON (DDS)
Entity Type:Individual
Prefix:
First Name:JAE YEON
Middle Name:
Last Name:YOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 S OLIVE ST APT 2809
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90014-3036
Mailing Address - Country:US
Mailing Address - Phone:706-980-4989
Mailing Address - Fax:
Practice Address - Street 1:16850 SAN FERNANDO MISSION BLVD
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-4247
Practice Address - Country:US
Practice Address - Phone:818-488-6068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO107128122300000X
CO00205284122300000X
FLDN27541122300000X
CA107128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA107128OtherSTATE LICENSE