Healthcare Provider Details

I. General information

NPI: 1922273036
Provider Name (Legal Business Name): DANIEL JEONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2008
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 MAIN ST
TEWKSBURY MA
01876-4774
US

IV. Provider business mailing address

1201 MAIN ST
TEWKSBURY MA
01876-4774
US

V. Phone/Fax

Practice location:
  • Phone: 978-851-5200
  • Fax:
Mailing address:
  • Phone: 978-851-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN1855177
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: