Provider Demographics
NPI:1568867596
Name:GO, JEONG CHUL
Entity Type:Individual
Prefix:
First Name:JEONG CHUL
Middle Name:
Last Name:GO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 WILSHIRE BLVD APT 612
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-5665
Mailing Address - Country:US
Mailing Address - Phone:857-294-8551
Mailing Address - Fax:
Practice Address - Street 1:1010 WILSHIRE BLVD APT 612
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-5665
Practice Address - Country:US
Practice Address - Phone:857-294-8551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist