Provider Demographics
NPI:1245728104
Name:JEON, KYOUNGSOO
Entity type:Individual
Prefix:
First Name:KYOUNGSOO
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10765 BENNETT RD
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:NY
Mailing Address - Zip Code:14048-3567
Mailing Address - Country:US
Mailing Address - Phone:716-366-6822
Mailing Address - Fax:
Practice Address - Street 1:10765 BENNETT RD
Practice Address - Street 2:
Practice Address - City:DUNKIRK
Practice Address - State:NY
Practice Address - Zip Code:14048-3567
Practice Address - Country:US
Practice Address - Phone:716-366-6822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-26
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025666122300000X
390200000X
NY062608122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program