Provider Demographics
NPI:1366606816
Name:OK, PETER SEONG JOON (DDS, MMSC)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:SEONG JOON
Last Name:OK
Suffix:
Gender:M
Credentials:DDS, MMSC
Other - Prefix:
Other - First Name:SEONG
Other - Middle Name:JOON
Other - Last Name:OK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:771 OLD NORCROSS RD
Mailing Address - Street 2:STE 125
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4978
Mailing Address - Country:US
Mailing Address - Phone:678-985-0550
Mailing Address - Fax:
Practice Address - Street 1:771 OLD NORCROSS RD
Practice Address - Street 2:STE 125
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4978
Practice Address - Country:US
Practice Address - Phone:678-985-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22248122300000X
GADN0146351223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist