Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | A109352 | CA |
NPI | 1417103946 |
---|---|
Provider Name | Young Jun |
First Address | Placentia, CA 92870-3006 |
Second Address | Placentia, CA 92870-3006 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/08/2008 |
Last Update Date | 15/06/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
55513 | STATE LICENSE (01) | CA |
A109352 | CALIFORNIA (01) | CA |