Healthcare Provider Details

I. General information

NPI: 1083303994
Provider Name (Legal Business Name): HANA VIVIAN JEONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 N WESTWOOD BLVD
POPLAR BLUFF MO
63901-3315
US

IV. Provider business mailing address

919 HARMONY RIDGE CT
SAINT PETERS MO
63376-2581
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-3042
  • Fax:
Mailing address:
  • Phone: 314-255-7423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026023587
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: