Provider Demographics
NPI:1013636455
Name:JEONG, WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 GALLERIA APT 3342
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5340
Mailing Address - Country:US
Mailing Address - Phone:515-203-5999
Mailing Address - Fax:
Practice Address - Street 1:2811 S LOOP 289 STE 12
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-1443
Practice Address - Country:US
Practice Address - Phone:806-748-9797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-26
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX389571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice