MEDICARE: DR. EOON HYE JI DDS, PH.D

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	107906	CA

General Provider Information

NPI Number	:	1942920194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EOON HYE JI DDS, PH.D

Provider Business Mailing Address
First Line	:	530 VETERAN AVE APT 307
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-8002
Country	:	US
Telephone Number	:	213-210-9134
Fax Number	:

Provider Business Practice Location Address
First Line	:	530 VETERAN AVE APT 307
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-8002
Country	:	US
Telephone Number	:	213-210-9134
Fax Number	:

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

Provider Enumeration Date	:	08/29/2022
Last Update Date	:	08/30/2022

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