MEDICARE: KAYLIN KYUNG YEON JU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	0401416217	VA

General Provider Information

NPI Number	:	1336613496
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAYLIN KYUNG YEON JU DDS

Provider Business Mailing Address
First Line	:	43459 HOPESTONE TER
Second Line	:
City	:	CHANTILLY
State	:	VA
Zip	:	20152-1992
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	202 S KING ST
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20175-3010
Country	:	US
Telephone Number	:	703-777-1162
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2019
Last Update Date	:	08/04/2020

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