Provider Demographics
NPI:1609208040
Name:JI, SUNG YEON (DDS)
Entity Type:Individual
Prefix:
First Name:SUNG YEON
Middle Name:
Last Name:JI
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 1:13190 SE 162ND AVE APT 219
Mailing Address - Street 2:
Mailing Address - City:HAPPY VALLEY
Mailing Address - State:OR
Mailing Address - Zip Code:97015-3780
Mailing Address - Country:US
Mailing Address - Phone:971-266-7043
Mailing Address - Fax:
Practice Address - Street 1:927 COUNTRY CLUB RD STE 100
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6018
Practice Address - Country:US
Practice Address - Phone:458-201-8471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029604122300000X
ORD10100122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist