Healthcare Provider Details

I. General information

NPI: 1578233557
Provider Name (Legal Business Name): SOMYUNG JI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2021
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 VAN BUREN BLVD
RIVERSIDE CA
92503-2066
US

IV. Provider business mailing address

714 TIVERTON AVE RM 10-165
LOS ANGELES CA
90095-8361
US

V. Phone/Fax

Practice location:
  • Phone: 951-352-5838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number106967
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number106967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: