Provider Demographics
NPI:1831313493
Name:SO, JAEMYUN
Entity Type:Individual
Prefix:
First Name:JAEMYUN
Middle Name:
Last Name:SO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 HANCOCK CT
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1604
Mailing Address - Country:US
Mailing Address - Phone:973-481-3900
Mailing Address - Fax:
Practice Address - Street 1:644 MT. PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-481-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist