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General NPI Number Information
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NPI Number | 1063530509
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Entity Type | Individual
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Provider Name | ILCHEON JOO D.D.S
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Gender | Male
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Dates
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Enumeration Date | 03/26/2007
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Last Update Date | 12/08/2009
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Provider Practice Location Address
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Address Line | 46 MIFFLIN ST
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City | PINE GROVE
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State | PA
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Zip | 17963-1318
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Country | US
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Telephone | 570-345-3495
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Fax | 570-345-3161
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Provider Business Mailing Address
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Address Line | 6690 HAUSER RD M101
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City | MACUNGIE
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State | PA
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Zip | 18062-8102
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS037775
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License Number State | PA
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