Basic Information
| Provider Information | |||||||||
| NPI: | 1093294266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOO | ||||||||
| FirstName: | SE JIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JOO | ||||||||
| OtherFirstName: | ERIC | ||||||||
| OtherMiddleName: | SEJIN | ||||||||
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| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15914 44TH AVE W APT O306 | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980876166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4086246950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4310 COLBY AVE STE 300 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8554336825 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | DE60868329 | WA | Y | Dental Providers | Dentist | General Practice |
No ID Information.