Provider Demographics
NPI:1205191533
Name:OH, JONG KEUN (DDS)
Entity type:Individual
Prefix:DR
First Name:JONG KEUN
Middle Name:
Last Name:OH
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 1:1124 S LAKE ST STE C
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4313
Mailing Address - Country:US
Mailing Address - Phone:817-332-9393
Mailing Address - Fax:
Practice Address - Street 1:1124 S LAKE ST STE C
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4313
Practice Address - Country:US
Practice Address - Phone:817-332-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0393961223G0001X
IL0190291651223G0001X
WI7003-151223G0001X
TX346581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice