1588303465 NPI number — JAE YOO, DDS, MSD, INC

Table of content: (NPI 1588303465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588303465 NPI number — JAE YOO, DDS, MSD, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAE YOO, DDS, MSD, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588303465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14021 MIDLAND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POWAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92064-3959
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-883-4842
Provider Business Mailing Address Fax Number:
858-883-4845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14021 MIDLAND RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92064-3959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-883-4842
Provider Business Practice Location Address Fax Number:
858-883-4845
Provider Enumeration Date:
05/31/2022

Additional Information

Authorized Official

Authorized Official Last Name:
YOO
Authorized Official First Name:
JAE
Authorized Official Middle Name:
Y
Authorized Official Title or Position:
OWNER DENTIST
Authorized Official Telephone Number:
858-883-4860

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 103617 . This is a "DENTIST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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