Provider Demographics
NPI:1215594346
Name:YOU, JAE YEON (DDS)
Entity type:Individual
Prefix:
First Name:JAE YEON
Middle Name:
Last Name:YOU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 CHANNELSIDE DR UNIT 2410
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5495
Mailing Address - Country:US
Mailing Address - Phone:706-980-4989
Mailing Address - Fax:
Practice Address - Street 1:1475 6TH ST NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-2365
Practice Address - Country:US
Practice Address - Phone:656-214-7589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-23
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL275411223G0001X
CO00205284122300000X
FLDN27541122300000X
CA107128122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA107128OtherSTATE LICENSE