Healthcare Provider Details

I. General information

NPI: 1811102346
Provider Name (Legal Business Name): PETER JEON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 CORPORATE PARK SUITE 200
IRVINE CA
92606-3122
US

IV. Provider business mailing address

62 CORPORATE PARK SUITE 200
IRVINE CA
92606-3122
US

V. Phone/Fax

Practice location:
  • Phone: 949-261-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number45377
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: