Provider Demographics
NPI:1639742570
Name:JEON, YOUNGIL
Entity Type:Individual
Prefix:
First Name:YOUNGIL
Middle Name:
Last Name:JEON
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 1:21700 LAURELRIM DR UNIT A
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3146
Mailing Address - Country:US
Mailing Address - Phone:571-249-7557
Mailing Address - Fax:
Practice Address - Street 1:38209 47TH ST E STE E
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93552-3113
Practice Address - Country:US
Practice Address - Phone:661-236-0046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1066151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice