Healthcare Provider Details

I. General information

NPI: 1902298649
Provider Name (Legal Business Name): MYUNG-HYUN BAE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 05/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 MAIN ST
BRIDGEPORT CT
06606-3609
US

IV. Provider business mailing address

101 JACKSON AVE 4F
MINEOLA NY
11501-2702
US

V. Phone/Fax

Practice location:
  • Phone: 267-939-0477
  • Fax:
Mailing address:
  • Phone: 267-939-0477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number011565
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: