MEDICARE: DR. JONG KEUN OH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS039396	PA
2	1223G0001X	General Practice Dentistry	019029165	IL
3	1223G0001X	General Practice Dentistry	7003-15	WI
4	1223G0001X	General Practice Dentistry	34658	TX

General Provider Information

NPI Number	:	1205191533
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONG KEUN OH DDS

Provider Business Mailing Address
First Line	:	1124 S LAKE ST STE C
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4313
Country	:	US
Telephone Number	:	817-332-9393
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 S LAKE ST STE C
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-4313
Country	:	US
Telephone Number	:	817-332-9393
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2012
Last Update Date	:	11/16/2019

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