Provider Demographics
NPI:1477282291
Name:IM, JINNA YUN JI (DMD)
Entity Type:Individual
Prefix:
First Name:JINNA
Middle Name:YUN JI
Last Name:IM
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 1:2150 W ALAMEDA RD UNIT 1169
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-1951
Mailing Address - Country:US
Mailing Address - Phone:808-383-0209
Mailing Address - Fax:
Practice Address - Street 1:742 E GLENDALE AVE STE 118
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-5352
Practice Address - Country:US
Practice Address - Phone:602-491-0887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-07
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist