=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891212866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEUSUNG YUN DENTAL P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2017
-----------------------------------------------------
Last Update Date | 08/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2262 BLUE STONE HILLS DR STE A
-----------------------------------------------------
City | HARRISONBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22801-5434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 540-433-3080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 BOGEY AVE
-----------------------------------------------------
City | NEW MARKET
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22844-9667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-710-5526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | KEUSUNG YUN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-710-5526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 0401415373
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------