Provider Demographics
NPI:1407333404
Name:JEONG, JAEYOON
Entity Type:Individual
Prefix:
First Name:JAEYOON
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 EASTSIDE ST APT 5040
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77098-3838
Mailing Address - Country:US
Mailing Address - Phone:917-880-5096
Mailing Address - Fax:
Practice Address - Street 1:1632 SPENCER HWY
Practice Address - Street 2:
Practice Address - City:SOUTH HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77587-3752
Practice Address - Country:US
Practice Address - Phone:713-910-1002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-23
Last Update Date:2019-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX344511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice