Healthcare Provider Details

I. General information

NPI: 1265844807
Provider Name (Legal Business Name): JAJUNG YOON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 03/02/2020
Certification Date: 03/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 COURTHOUSE RD SE
LOS LUNAS NM
87031-6811
US

IV. Provider business mailing address

219 COURTHOUSE RD SE
LOS LUNAS NM
87031-6811
US

V. Phone/Fax

Practice location:
  • Phone: 848-565-5070
  • Fax:
Mailing address:
  • Phone: 848-565-5070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901021257
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD4403
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: