Provider Demographics
NPI:1780030304
Name:BOM SEOK JEON, DDS, INC
Entity Type:Organization
Organization Name:BOM SEOK JEON, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BOM SEOK
Authorized Official - Middle Name:
Authorized Official - Last Name:JEON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-700-5090
Mailing Address - Street 1:1401 S BROOKHURST RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4492
Mailing Address - Country:US
Mailing Address - Phone:714-879-2828
Mailing Address - Fax:
Practice Address - Street 1:1401 S BROOKHURST RD STE 104
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4492
Practice Address - Country:US
Practice Address - Phone:714-879-2828
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-12
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62451122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1295175859OtherDENTICAL