Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 4120 | WV |
N | 1223P0700X | Prosthodontist | 23 | WV |
Y | 1223S0112X | Oral and Maxillofacial Surgeon | S74 | MN |
NPI | 1154648079 |
---|---|
Provider Name | Dr. Soo Cheol Jeong |
First Address | Rochester, MN 55905-0001 |
Second Address | Rochester, MN 55905-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/05/2010 |
Last Update Date | 05/10/2021 |