Healthcare Provider Details

I. General information

NPI: 1871286757
Provider Name (Legal Business Name): SOYOUNG RYU CHATFIELD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 05/24/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4063 MANNHEIM RD
JASPER IN
47546-2664
US

IV. Provider business mailing address

227 GERONIMO CT
HENDERSON NV
89074-4107
US

V. Phone/Fax

Practice location:
  • Phone: 702-377-9123
  • Fax:
Mailing address:
  • Phone: 702-377-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12014973A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: