Provider Demographics
NPI:1376055574
Name:SB DENTAL LLC
Entity Type:Organization
Organization Name:SB DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEP
Authorized Official - Prefix:
Authorized Official - First Name:JAJUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:718-309-7310
Mailing Address - Street 1:219 COURTHOUSE RD SE
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-6811
Mailing Address - Country:US
Mailing Address - Phone:505-865-4341
Mailing Address - Fax:
Practice Address - Street 1:219 COURTHOUSE RD SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6811
Practice Address - Country:US
Practice Address - Phone:505-865-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-27
Last Update Date:2017-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD4403261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM80133321Medicaid