=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649761834
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YOON HWAN EDWARD JEONG DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2018
-----------------------------------------------------
Last Update Date | 04/30/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 MAIN ST # 304
-----------------------------------------------------
City | HAVERHILL
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01830-5045
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-330-6462
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 449 CANAL ST UNIT 229
-----------------------------------------------------
City | SOMERVILLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02145-4331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-541-8679
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DN1858024
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------