MEDICARE: EVERSMILE DENTIST PLLC

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

General Provider Information

NPI Number	:	1639961410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERSMILE DENTIST PLLC

Provider Business Mailing Address
First Line	:	3624 JOE BATTLE BLVD UNIT 110
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-2628
Country	:	US
Telephone Number	:	915-219-7773
Fax Number	:	915-219-7078

Provider Business Practice Location Address
First Line	:	3624 JOE BATTLE BLVD UNIT 110
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-2628
Country	:	US
Telephone Number	:	915-219-7773
Fax Number	:	915-219-7078

Authorized Official
Title or Position	:	OWNER
Name	:	JAEGUN AHN
Credential	:
Telephone Number	:	562-331-9840

Provider Enumeration Date	:	05/19/2025
Last Update Date	:	05/19/2025

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