Provider Demographics
NPI:1962247817
Name:JEON, DAE MIN (DDS)
Entity type:Individual
Prefix:
First Name:DAE MIN
Middle Name:
Last Name:JEON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14184 FURLONG WAY
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-6158
Mailing Address - Country:US
Mailing Address - Phone:240-654-2137
Mailing Address - Fax:
Practice Address - Street 1:US DENTAL HEALTH ACTIVITY 36000 SHOEMAKER LANE, SUITE 1
Practice Address - Street 2:
Practice Address - City:FORT CAVAZOS
Practice Address - State:TX
Practice Address - Zip Code:76544
Practice Address - Country:US
Practice Address - Phone:254-287-3105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX406351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice