Provider Demographics
NPI:1659885523
Name:BSJC, LLC
Entity Type:Organization
Organization Name:BSJC, LLC
Other - Org Name:PREMIER DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JONGSUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:671-300-3221
Mailing Address - Street 1:692 N MARINE CORPS DR STE 301
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-4454
Mailing Address - Country:US
Mailing Address - Phone:671-300-3221
Mailing Address - Fax:671-300-3223
Practice Address - Street 1:692 N MARINE CORPS DR STE 301
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-4454
Practice Address - Country:US
Practice Address - Phone:671-300-3221
Practice Address - Fax:671-300-3223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD10141223E0200X
1223G0001X, 1223P0221X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty