Provider Demographics
NPI:1457970147
Name:MOON, SOPHIE JU HYUNG
Entity Type:Individual
Prefix:
First Name:SOPHIE
Middle Name:JU HYUNG
Last Name:MOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4529 GILBERTSON RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22032-3615
Mailing Address - Country:US
Mailing Address - Phone:202-480-4420
Mailing Address - Fax:
Practice Address - Street 1:801 S PAULINA ST RM 131
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-7210
Practice Address - Country:US
Practice Address - Phone:312-996-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL019.0325441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program