MEDICARE: SEUNG YEON BAE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	30.025688	OH

General Provider Information

NPI Number	:	1518452028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEUNG YEON BAE

Provider Business Mailing Address
First Line	:	22301 ROCKSIDE RD
Second Line	:
City	:	BEDFORD
State	:	OH
Zip	:	44146-1509
Country	:	US
Telephone Number	:	240-818-6177
Fax Number	:

Provider Business Practice Location Address
First Line	:	22301 ROCKSIDE RD
Second Line	:
City	:	BEDFORD
State	:	OH
Zip	:	44146-1509
Country	:	US
Telephone Number	:	440-232-4222
Fax Number	:

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

Provider Enumeration Date	:	06/27/2018
Last Update Date	:	08/01/2022

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