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General NPI Number Information
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NPI Number | 1699006452
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Entity Type | Organization
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Legal Business Name | ILCHEON JOO DDS PC
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Dates
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Enumeration Date | 01/19/2010
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Last Update Date | 01/19/2010
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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 | 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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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. ILCHEON JOO
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Credential | DDS
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Telephone | 570-345-3495
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DS037775
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License Number State | PA
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