Provider Demographics
NPI:1588643696
Name:JIN, SU K (DDS)
Entity Type:Individual
Prefix:DR
First Name:SU
Middle Name:K
Last Name:JIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20927 35TH AVE
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-1451
Mailing Address - Country:US
Mailing Address - Phone:917-650-3735
Mailing Address - Fax:
Practice Address - Street 1:3901 MAIN ST
Practice Address - Street 2:SUITE #303
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5432
Practice Address - Country:US
Practice Address - Phone:718-359-7605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048441122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02254259Medicaid