Basic Information
| Provider Information | |||||||||
| NPI: | 1548581937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | YOON | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HANNAH | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | Y | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DDS | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631083201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3144958179 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4055 LINDELL BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145357701 | ||||||||
| FaxNumber: | 3145350385 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2010 | ||||||||
| LastUpdateDate: | 03/31/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2010016296 | MO | Y | Dental Providers | Dentist | 122300000X | 2466 | MT | N | Dental Providers | Dentist | 122300000X | 12011923A | IN | N | Dental Providers | Dentist |
No ID Information.