Provider Demographics
NPI:1629415625
Name:YI, SUJIN (DDS)
Entity Type:Individual
Prefix:
First Name:SUJIN
Middle Name:
Last Name:YI
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 1:580 HIDDEN MARSH RD
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8835
Mailing Address - Country:US
Mailing Address - Phone:303-795-1107
Mailing Address - Fax:
Practice Address - Street 1:5050 S FEDERAL BLVD
Practice Address - Street 2:38
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80110-6361
Practice Address - Country:US
Practice Address - Phone:303-795-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002018831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice