Provider Demographics
NPI:1134107253
Name:NAM, SOO JIN (DDS)
Entity type:Individual
Prefix:DR
First Name:SOO JIN
Middle Name:
Last Name:NAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SOO JIN
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:770 VISTA BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097
Mailing Address - Country:US
Mailing Address - Phone:770-845-4406
Mailing Address - Fax:
Practice Address - Street 1:4195 PLEASANT HILL RD STE 200
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6385
Practice Address - Country:US
Practice Address - Phone:770-814-7533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-09
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012863122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA896730672AMedicaid