Healthcare Provider Details

I. General information

NPI: 1609136969
Provider Name (Legal Business Name): YEJOON SUH DDS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3420 AVENUE K 140
PLANO TX
75074-2333
US

IV. Provider business mailing address

3420 AVENUE K 140
PLANO TX
75074-2333
US

V. Phone/Fax

Practice location:
  • Phone: 310-739-3791
  • Fax:
Mailing address:
  • Phone: 310-739-3791
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25702
License Number StateTX

VIII. Authorized Official

Name: YE JOON SUH
Title or Position: OWNER
Credential: DDS
Phone: 310-739-3791