Provider Demographics
NPI:1962514695
Name:SON, JEONG H (DDS)
Entity type:Individual
Prefix:DR
First Name:JEONG
Middle Name:H
Last Name:SON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1363 OLIVER RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-3470
Mailing Address - Country:US
Mailing Address - Phone:707-429-1708
Mailing Address - Fax:707-429-1794
Practice Address - Street 1:1363 OLIVER RD
Practice Address - Street 2:SUITE A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-3470
Practice Address - Country:US
Practice Address - Phone:707-429-1708
Practice Address - Fax:707-429-1794
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
20-3314042OtherTAX ID