Provider Demographics
NPI:1679964951
Name:STATE FAMILY DENTAL
Entity Type:Organization
Organization Name:STATE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NORAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-567-2995
Mailing Address - Street 1:516 N MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2806
Mailing Address - Country:US
Mailing Address - Phone:646-236-0717
Mailing Address - Fax:
Practice Address - Street 1:8928 STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2926
Practice Address - Country:US
Practice Address - Phone:323-567-2995
Practice Address - Fax:323-567-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA577371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty