Provider Demographics
NPI:1598910259
Name:IM, HYESUNG (DDS)
Entity Type:Individual
Prefix:
First Name:HYESUNG
Middle Name:
Last Name:IM
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 1:600 PINE HOLLOW RD
Mailing Address - Street 2:4-1A
Mailing Address - City:EAST NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:11732-1042
Mailing Address - Country:US
Mailing Address - Phone:917-653-7145
Mailing Address - Fax:
Practice Address - Street 1:600 PINE HOLLOW RD
Practice Address - Street 2:4-1A
Practice Address - City:EAST NORWICH
Practice Address - State:NY
Practice Address - Zip Code:11732-1042
Practice Address - Country:US
Practice Address - Phone:917-653-7145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-22
Last Update Date:2008-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053915-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice