Basic Information
| Provider Information | |||||||||
| NPI: | 1558372235 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUK | ||||||||
| FirstName: | HYE JUNG | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4030 LAWRENCEVILLE HWY NW | ||||||||
| Address2: | |||||||||
| City: | LILBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300473011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782525665 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4030 LAWRENCEVILLE HWY NW | ||||||||
| Address2: | |||||||||
| City: | LILBURN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300473011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782525665 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 6687 | AZ | N | Dental Providers | Dentist | 1223G0001X | DN014221 | GA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 048090 | 05 | AZ | MEDICAID |