Healthcare Provider Details

I. General information

NPI: 1699683185
Provider Name (Legal Business Name): JEONGI WON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4799 ATLANTA HWY STE 500
LOGANVILLE GA
30052-7467
US

IV. Provider business mailing address

4799 ATLANTA HWY STE 500
LOGANVILLE GA
30052-7467
US

V. Phone/Fax

Practice location:
  • Phone: 949-373-6930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN124322
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: