=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295381135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSIE YOUN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2019
-----------------------------------------------------
Last Update Date | 08/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 687 S VERMONT AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90005-1349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-381-7770
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 S BERENDO ST APT 329
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90020-2059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-528-1099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 104208
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------