Provider Demographics
NPI:1366850778
Name:BENNETT JEONG, DDS, INC.
Entity Type:Organization
Organization Name:BENNETT JEONG, DDS, INC.
Other - Org Name:VIA VERDE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNETT
Authorized Official - Middle Name:
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-599-8331
Mailing Address - Street 1:1057 VIA VERDE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4347
Mailing Address - Country:US
Mailing Address - Phone:909-599-8331
Mailing Address - Fax:
Practice Address - Street 1:1057 VIA VERDE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4347
Practice Address - Country:US
Practice Address - Phone:909-599-8331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63595261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental