Provider Demographics
NPI:1629132303
Name:HONG, SOOMIN (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:SOOMIN
Middle Name:
Last Name:HONG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 N COPPELL RD APT 3206
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2053
Mailing Address - Country:US
Mailing Address - Phone:415-690-0611
Mailing Address - Fax:
Practice Address - Street 1:620 N COPPELL RD APT 3206
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2053
Practice Address - Country:US
Practice Address - Phone:415-690-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN-88251223G0001X
CA1020801223X0400X
TX347231223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO71001549Medicaid