Provider Demographics
NPI:1295175859
Name:JEON, BOM SEOK
Entity type:Individual
Prefix:
First Name:BOM SEOK
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 1:1401 S BROOKHURST RD STE 104
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4492
Mailing Address - Country:US
Mailing Address - Phone:714-879-2828
Mailing Address - Fax:
Practice Address - Street 1:1401 S BROOKHURST RD
Practice Address - Street 2:STE 104
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4492
Practice Address - Country:US
Practice Address - Phone:714-879-2828
Practice Address - Fax:714-879-2226
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA624511223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice