Provider Demographics
NPI:1114083193
Name:IM, TED TAE YUL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TED
Middle Name:TAE YUL
Last Name:IM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23205 SUNNYMEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5246
Mailing Address - Country:US
Mailing Address - Phone:951-242-6242
Mailing Address - Fax:951-242-4782
Practice Address - Street 1:23205 SUNNYMEAD BLVD
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5246
Practice Address - Country:US
Practice Address - Phone:951-242-6242
Practice Address - Fax:951-242-4782
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD40950Medicaid