=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447773346
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SOO JEEN JUN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2017
-----------------------------------------------------
Last Update Date | 04/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5805 MCNUTT RD # F
-----------------------------------------------------
City | SUNLAND PARK
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88008-8001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-502-4422
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11368 ACOMA ST
-----------------------------------------------------
City | EL PASO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79934-2872
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | DD5579
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------