Provider Demographics
NPI:1043504954
Name:AHN, MICHELLE SOOJUNG (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:SOOJUNG
Last Name:AHN
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1444 AVIATION BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4001
Mailing Address - Country:US
Mailing Address - Phone:310-376-2460
Mailing Address - Fax:310-376-7273
Practice Address - Street 1:1444 AVIATION BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-4001
Practice Address - Country:US
Practice Address - Phone:310-376-2460
Practice Address - Fax:310-376-7273
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX288221223G0001X
CA646581223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223G0001XDental ProvidersDentistGeneral Practice