Provider Demographics
NPI:1841524568
Name:YOON, JAEWON (DMD)
Entity type:Individual
Prefix:
First Name:JAEWON
Middle Name:
Last Name:YOON
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 1:14631 LEE HWY STE 116
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20121-5825
Mailing Address - Country:US
Mailing Address - Phone:703-447-5204
Mailing Address - Fax:
Practice Address - Street 1:14631 LEE HWY STE 116
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:VA
Practice Address - Zip Code:20121-5825
Practice Address - Country:US
Practice Address - Phone:703-447-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD146791223G0001X
VA04014126481223G0001X
PADS038113122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD026866600Medicaid