Provider Demographics
NPI:1235721523
Name:PHIYO, JOONHO
Entity Type:Individual
Prefix:
First Name:JOONHO
Middle Name:
Last Name:PHIYO
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 1:393 BELLE TERRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-2433
Mailing Address - Country:US
Mailing Address - Phone:985-652-8767
Mailing Address - Fax:
Practice Address - Street 1:393 BELLE TERRE BLVD
Practice Address - Street 2:
Practice Address - City:LA PLACE
Practice Address - State:LA
Practice Address - Zip Code:70068-2433
Practice Address - Country:US
Practice Address - Phone:985-652-8767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-08
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA390200000X
LA72091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program