Provider Demographics
NPI:1912644022
Name:JL DENTAL GROUP
Entity Type:Organization
Organization Name:JL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KWUNHO
Authorized Official - Middle Name:KELVIN
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:217-722-6415
Mailing Address - Street 1:3101 VILLAGE OFFICE PL
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-7673
Mailing Address - Country:US
Mailing Address - Phone:217-352-4646
Mailing Address - Fax:
Practice Address - Street 1:3101 VILLAGE OFFICE PL
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-7673
Practice Address - Country:US
Practice Address - Phone:217-352-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental