Provider Demographics
NPI:1225010549
Name:YOO, JAESUK
Entity Type:Individual
Prefix:
First Name:JAESUK
Middle Name:
Last Name:YOO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 N. AVIATION BLVD
Mailing Address - Street 2:61 MDOS/SGOD
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-2808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:483 N. AVIATION BLVD
Practice Address - Street 2:61 MDOS/SGOD
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-2808
Practice Address - Country:US
Practice Address - Phone:310-653-6844
Practice Address - Fax:310-653-6762
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice