Provider Demographics
NPI:1285848218
Name:YIM, HAE SU (DMD)
Entity Type:Individual
Prefix:DR
First Name:HAE SU
Middle Name:
Last Name:YIM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5041 VAIL PINE PL
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-9463
Mailing Address - Country:US
Mailing Address - Phone:614-599-0065
Mailing Address - Fax:937-642-2490
Practice Address - Street 1:1127 W 5TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-9282
Practice Address - Country:US
Practice Address - Phone:937-642-2400
Practice Address - Fax:937-642-2490
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2572470Medicaid