Provider Demographics
NPI:1659454601
Name:SOHN, ILKWAN I (DDS)
Entity Type:Individual
Prefix:DR
First Name:ILKWAN
Middle Name:I
Last Name:SOHN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ERIC
Other - Middle Name:I
Other - Last Name:SOHN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:15 OREGON AVE
Mailing Address - Street 2:206
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-7461
Mailing Address - Country:US
Mailing Address - Phone:253-475-0262
Mailing Address - Fax:253-475-0266
Practice Address - Street 1:15 OREGON AVE
Practice Address - Street 2:206
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-7461
Practice Address - Country:US
Practice Address - Phone:253-475-0262
Practice Address - Fax:253-475-0266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5011770Medicaid