Provider Demographics
NPI:1952665846
Name:JEON, SI EUN (D D S)
Entity Type:Individual
Prefix:DR
First Name:SI EUN
Middle Name:
Last Name:JEON
Suffix:
Gender:F
Credentials:D D S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12215 HAMPTON WAY DR STE 107
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6295
Mailing Address - Country:US
Mailing Address - Phone:919-556-1422
Mailing Address - Fax:919-556-2455
Practice Address - Street 1:12215 HAMPTON WAY DR STE 107
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6295
Practice Address - Country:US
Practice Address - Phone:919-556-1422
Practice Address - Fax:919-556-2455
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC93531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice