Provider Demographics
NPI:1801531371
Name:AN, JI HYUN
Entity type:Individual
Prefix:
First Name:JI
Middle Name:HYUN
Last Name:AN
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 1:1666 S DOBSON RD APT 4062
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-1614
Mailing Address - Country:US
Mailing Address - Phone:303-748-8796
Mailing Address - Fax:
Practice Address - Street 1:23844 S POWER RD STE B-106
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-6152
Practice Address - Country:US
Practice Address - Phone:602-661-6983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-29
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD011684122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist