Healthcare Provider Details

I. General information

NPI: 1871659987
Provider Name (Legal Business Name): JEAN WOO, DDS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 STAFF DR NE # B
FORT WALTON BEACH FL
32548-5062
US

IV. Provider business mailing address

136 STAFF DR NE # B
FORT WALTON BEACH FL
32548-5062
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-7177
  • Fax: 850-243-4929
Mailing address:
  • Phone: 850-243-7177
  • Fax: 850-243-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDN10017
License Number StateFL

VIII. Authorized Official

Name: DR. JEAN WOO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 850-243-7177