Provider Demographics
NPI:1356070478
Name:AHN, SOO IN (DMD)
Entity Type:Individual
Prefix:
First Name:SOO IN
Middle Name:
Last Name:AHN
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 1:31 BEACH ST APT 805
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1603
Mailing Address - Country:US
Mailing Address - Phone:857-265-9292
Mailing Address - Fax:
Practice Address - Street 1:1000 BALD HILL RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-0506
Practice Address - Country:US
Practice Address - Phone:401-822-1866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN03617122300000X
MADN1859464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist