Provider Demographics
NPI:1952890766
Name:JEONG, DAIN (ND)
Entity Type:Individual
Prefix:
First Name:DAIN
Middle Name:
Last Name:JEONG
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:DAIN
Other - Middle Name:ALICE
Other - Last Name:JEONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ND
Mailing Address - Street 1:22691 LAMBERT ST STE 505
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-1614
Mailing Address - Country:US
Mailing Address - Phone:480-399-3639
Mailing Address - Fax:
Practice Address - Street 1:22691 LAMBERT ST STE 505
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-1614
Practice Address - Country:US
Practice Address - Phone:480-399-3639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAND935175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath