Provider Demographics
NPI:1669221198
Name:JO, YOUNG-IL
Entity type:Individual
Prefix:
First Name:YOUNG-IL
Middle Name:
Last Name:JO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 W MARKET ST APT 736
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2789
Mailing Address - Country:US
Mailing Address - Phone:973-342-7262
Mailing Address - Fax:
Practice Address - Street 1:9610 SIERRA AVE STE 200
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-2456
Practice Address - Country:US
Practice Address - Phone:909-219-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1105651223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist