Healthcare Provider Details

I. General information

NPI: 1427015874
Provider Name (Legal Business Name): SUNG JOO JEONG D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 10/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 BROWNING RD RM U15
PENNSAUKEN NJ
08109
US

IV. Provider business mailing address

6650 BROWNING RD RM U15
PENNSAUKEN NJ
08109-1479
US

V. Phone/Fax

Practice location:
  • Phone: 856-324-0777
  • Fax: 856-324-0503
Mailing address:
  • Phone: 856-324-0777
  • Fax: 856-324-0503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS036185
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02709200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: