Provider Demographics
NPI:1407476799
Name:JEOUNG, JONG IN (DMD)
Entity Type:Individual
Prefix:
First Name:JONG
Middle Name:IN
Last Name:JEOUNG
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 1:1106 MICHIGAN CIR
Mailing Address - Street 2:
Mailing Address - City:HOSCHTON
Mailing Address - State:GA
Mailing Address - Zip Code:30548-5561
Mailing Address - Country:US
Mailing Address - Phone:678-770-0839
Mailing Address - Fax:
Practice Address - Street 1:4536 NELSON BROGDON BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-7516
Practice Address - Country:US
Practice Address - Phone:678-730-2005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-16
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1228621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice