Provider Demographics
NPI:1740641653
Name:JUNG, JIYOUNG MOON (DDS)
Entity type:Individual
Prefix:DR
First Name:JIYOUNG
Middle Name:MOON
Last Name:JUNG
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 1:1101 ALEXIS CT # 101
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-3338
Mailing Address - Country:US
Mailing Address - Phone:817-466-1200
Mailing Address - Fax:817-466-1201
Practice Address - Street 1:1101 ALEXIS CT # 101
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-3338
Practice Address - Country:US
Practice Address - Phone:817-466-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-19
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311811223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice