Provider Demographics
NPI:1225220502
Name:AHN, YONG SOO (DDS)
Entity Type:Individual
Prefix:DR
First Name:YONG SOO
Middle Name:
Last Name:AHN
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 1:2042 E 115TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2330
Mailing Address - Country:US
Mailing Address - Phone:201-406-2777
Mailing Address - Fax:
Practice Address - Street 1:1390 S ARCH AVE
Practice Address - Street 2:
Practice Address - City:ALLIANCE
Practice Address - State:OH
Practice Address - Zip Code:44601-4111
Practice Address - Country:US
Practice Address - Phone:330-821-3961
Practice Address - Fax:330-821-0232
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0553491223P0221X
OH30-0240351223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0087022Medicaid