MEDICARE: WONJUNG JEONG 1223G0001X

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	49341	CA

General Provider Information

NPI Number	:	1396809240
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WONJUNG JEONG 1223G0001X

Provider Business Mailing Address
First Line	:	8543 LUXOR ST
Second Line	:
City	:	DOWNEY
State	:	CA
Zip	:	90241-5135
Country	:	US
Telephone Number	:	562-862-9499
Fax Number	:

Provider Business Practice Location Address
First Line	:	936 S ALVARADO ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-3008
Country	:	US
Telephone Number	:	213-380-1996
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	12/11/2007

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