Provider Demographics
NPI:1295212629
Name:YI, CHAERYUN (DMD)
Entity Type:Individual
Prefix:
First Name:CHAERYUN
Middle Name:
Last Name:YI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 FELL ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-3586
Mailing Address - Country:US
Mailing Address - Phone:781-883-2081
Mailing Address - Fax:
Practice Address - Street 1:413 PULASKI HWY STE 107
Practice Address - Street 2:
Practice Address - City:JOPPA
Practice Address - State:MD
Practice Address - Zip Code:21085-3626
Practice Address - Country:US
Practice Address - Phone:410-679-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD166081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice