Healthcare Provider Details

I. General information

NPI: 1457970147
Provider Name (Legal Business Name): SOPHIE JU HYUNG MOON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 06/23/2022
Certification Date: 06/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S PAULINA ST RM 131
CHICAGO IL
60612-7210
US

IV. Provider business mailing address

4529 GILBERTSON RD
FAIRFAX VA
22032-3615
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-7138
  • Fax:
Mailing address:
  • Phone: 202-480-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.032544
License Number StateIL
# 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: