Provider Demographics
NPI:1942955216
Name:JUN A. SOETANTO DMD LLC
Entity Type:Organization
Organization Name:JUN A. SOETANTO DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOETANTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:484-557-4808
Mailing Address - Street 1:2266 KRESGE DR
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:OH
Mailing Address - Zip Code:44001-1260
Mailing Address - Country:US
Mailing Address - Phone:440-960-0090
Mailing Address - Fax:
Practice Address - Street 1:2266 KRESGE DR
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1260
Practice Address - Country:US
Practice Address - Phone:440-960-0090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty