Provider Demographics
NPI:1275676785
Name:AHN, JIN MO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIN
Middle Name:MO
Last Name:AHN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 MAIN AVE N
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-9208
Mailing Address - Country:US
Mailing Address - Phone:503-815-1777
Mailing Address - Fax:503-815-1860
Practice Address - Street 1:2503 MAIN AVE N
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-9208
Practice Address - Country:US
Practice Address - Phone:503-815-1777
Practice Address - Fax:503-815-1860
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD69791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice