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General NPI Number Information
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NPI Number | 1932541521
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Entity Type | Individual
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Provider Name | SONAM JOON SOOD
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Gender | Female
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Dates
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Enumeration Date | 07/23/2013
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Last Update Date | 07/23/2013
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Provider Practice Location Address
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Address Line | 134 W 111TH ST
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City | CHICAGO
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State | IL
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Zip | 60628-4215
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Country | US
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Telephone | 773-995-3024
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Fax |
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Provider Business Mailing Address
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Address Line | 831 W 14TH PL
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City | CHICAGO
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State | IL
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Zip | 60608-2245
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Country | US
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Telephone | 630-373-1375
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019029532
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License Number State | IL
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