Provider Demographics
NPI:1922403815
Name:JEONG, JAEEUN
Entity Type:Individual
Prefix:DR
First Name:JAEEUN
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3530 WILSHIRE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2324
Mailing Address - Country:US
Mailing Address - Phone:213-739-2828
Mailing Address - Fax:
Practice Address - Street 1:3530 WILSHIRE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2324
Practice Address - Country:US
Practice Address - Phone:213-739-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-04
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63942122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist