Provider Demographics
NPI:1912296898
Name:JIN, PETER HYUNGBAIK (DDS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:HYUNGBAIK
Last Name:JIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 BROAD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1607
Mailing Address - Country:US
Mailing Address - Phone:201-592-0111
Mailing Address - Fax:
Practice Address - Street 1:535 BROAD AVE FL 2
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1607
Practice Address - Country:US
Practice Address - Phone:201-592-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-31
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0560941223G0001X
NJ22DI02586300122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice