Provider Demographics
NPI:1205167186
Name:YOU, JACQUELINE SOOMIN (DMD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SOOMIN
Last Name:YOU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 RANDOLPH RD STE 115
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-2260
Mailing Address - Country:US
Mailing Address - Phone:301-770-7710
Mailing Address - Fax:
Practice Address - Street 1:4701 RANDOLPH RD STE 115
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-2260
Practice Address - Country:US
Practice Address - Phone:301-770-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-17
Last Update Date:2010-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist