Provider Demographics
NPI:1750736112
Name:JEONG, JAMES (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 CLIFTON RD CLINIC B
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD CLINIC B
Practice Address - Street 2:SUITE 2300
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322-0312
Practice Address - Country:US
Practice Address - Phone:404-778-4500
Practice Address - Fax:404-778-5879
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI2951000876390200000X
GADN122860204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program