Provider Demographics
NPI:1225274392
Name:JIN, HO JU (DDS)
Entity Type:Individual
Prefix:
First Name:HO JU
Middle Name:
Last Name:JIN
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 1:4007 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3401
Mailing Address - Country:US
Mailing Address - Phone:213-385-1325
Mailing Address - Fax:213-380-9842
Practice Address - Street 1:4007 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3401
Practice Address - Country:US
Practice Address - Phone:213-385-1325
Practice Address - Fax:213-380-9842
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-19
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD53913Medicaid