Provider Demographics
NPI:1245939438
Name:JEONG, SU YOUNG DELPHINE (DMD)
Entity type:Individual
Prefix:DR
First Name:SU YOUNG
Middle Name:DELPHINE
Last Name:JEONG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:DELPHINE
Other - Middle Name:SUYOUNG
Other - Last Name:JEONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2606 S 107TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85209-7916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 OMINGMAK STREET
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE BAY
Practice Address - State:NUNAVUT
Practice Address - Zip Code:X0B0C0
Practice Address - Country:CA
Practice Address - Phone:514-912-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK198530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist