Healthcare Provider Details

I. General information

NPI: 1073217444
Provider Name (Legal Business Name): JUNG IL YOON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/26/2026
Certification Date: 07/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20350 WATER TOWER BLVD
BROOKFIELD WI
53045-3558
US

IV. Provider business mailing address

20350 WATER TOWER BLVD
BROOKFIELD WI
53045-3558
US

V. Phone/Fax

Practice location:
  • Phone: 262-327-6100
  • Fax: 262-717-9642
Mailing address:
  • Phone: 262-327-6100
  • Fax: 262-717-9642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601855
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6002167-15
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2901601855
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: