Healthcare Provider Details

I. General information

NPI: 1851452353
Provider Name (Legal Business Name): DR. JAE SIK HUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 MONTGOMERY DR
SANTA ROSA CA
95405-5282
US

IV. Provider business mailing address

130 SAN FELIPE AVE
SAN FRANCISCO CA
94127-2048
US

V. Phone/Fax

Practice location:
  • Phone: 707-537-3601
  • Fax:
Mailing address:
  • Phone: 415-337-6507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number54911
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: