Healthcare Provider Details

I. General information

NPI: 1093555906
Provider Name (Legal Business Name): NOAH SOO PALENCIA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25501 BRAINARD AVE
APO AA
30905
US

IV. Provider business mailing address

1065 WILLIAMSBURG WAY APT 4410
EVANS GA
30809-7645
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-7050
  • Fax:
Mailing address:
  • Phone: 657-243-5498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS113310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: