Provider Demographics
NPI:1093294266
Name:JOO, SE JIN (DDS)
Entity Type:Individual
Prefix:
First Name:SE JIN
Middle Name:
Last Name:JOO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:SEJIN
Other - Last Name:JOO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:15914 44TH AVE W APT O306
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-6166
Mailing Address - Country:US
Mailing Address - Phone:408-624-6950
Mailing Address - Fax:
Practice Address - Street 1:4310 COLBY AVE STE 300
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-2338
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608683291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice