Healthcare Provider Details

I. General information

NPI: 1245913425
Provider Name (Legal Business Name): WONGYUN JEUNG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2023
Last Update Date: 08/14/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11461 RICHARDSON ST
LOMA LINDA CA
92354-3437
US

IV. Provider business mailing address

11461 RICHARDSON ST
LOMA LINDA CA
92354-3437
US

V. Phone/Fax

Practice location:
  • Phone: 909-222-3559
  • Fax:
Mailing address:
  • Phone: 909-222-3559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number109091
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: