Provider Demographics
NPI:1104042118
Name:AHN, TAEJOON (DMD)
Entity Type:Individual
Prefix:
First Name:TAEJOON
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 MOODY ST
Mailing Address - Street 2:
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453
Mailing Address - Country:US
Mailing Address - Phone:781-647-8000
Mailing Address - Fax:781-647-8111
Practice Address - Street 1:225 MOODY ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453
Practice Address - Country:US
Practice Address - Phone:781-647-8000
Practice Address - Fax:781-647-8111
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist