MEDICARE: GRACE EUNHEE JEONG D.D.S.

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	6918	AZ

General Provider Information

NPI Number	:	1679795322
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE EUNHEE JEONG D.D.S.

Provider Business Mailing Address
First Line	:	20401 N 19TH AVE APT 2100
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85027-3579
Country	:	US
Telephone Number	:	623-337-7553
Fax Number	:

Provider Business Practice Location Address
First Line	:	5940 W UNION HILLS DR STE F110
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-1303
Country	:	US
Telephone Number	:	602-978-9575
Fax Number	:

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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