Basic Information
Provider Information
NPI: 1477282291
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IM
FirstName: JINNA
MiddleName: YUN JI
NamePrefix:  
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2150 W ALAMEDA RD UNIT 1169
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850851951
CountryCode: US
TelephoneNumber: 8083830209
FaxNumber:  
Practice Location
Address1: 742 E GLENDALE AVE STE 118
Address2:  
City: PHOENIX
State: AZ
PostalCode: 850205352
CountryCode: US
TelephoneNumber: 6024910887
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/07/2022
LastUpdateDate: 06/07/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 06/06/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000XD011408AZY Dental ProvidersDentist 

No ID Information.


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