Provider Demographics
NPI:1689463978
Name:JEONG, DIANE (DMD)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:JEONG
Suffix:
Gender:
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ELMWOOD AVENUE
Mailing Address - Street 2:BOX 683
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 ELMWOOD AVENUE
Practice Address - Street 2:BOX 683
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620
Practice Address - Country:US
Practice Address - Phone:585-275-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program