=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629610738
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HA RA JEON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2019
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2492 WALNUT AVE STE 200
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-6960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-679-6000
-----------------------------------------------------
Fax | 949-679-6001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2492 WALNUT AVE STE 200
-----------------------------------------------------
City | TUSTIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92780-6960
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-679-6000
-----------------------------------------------------
Fax | 949-679-6001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number | 101866
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------