Provider Demographics
NPI:1275912248
Name:PALISADES PARK BO ORTHODONTICS
Entity Type:Organization
Organization Name:PALISADES PARK BO ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BO
Authorized Official - Middle Name:YOUNG
Authorized Official - Last Name:YUN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-242-9300
Mailing Address - Street 1:309A BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1620
Mailing Address - Country:US
Mailing Address - Phone:201-242-9300
Mailing Address - Fax:201-242-3361
Practice Address - Street 1:309A BROAD AVE
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1620
Practice Address - Country:US
Practice Address - Phone:201-242-9300
Practice Address - Fax:201-242-3361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-23
Last Update Date:2015-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI024048021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty