Provider Demographics
NPI:1902314834
Name:YOO, JAE YOUNG (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:JAE
Middle Name:YOUNG
Last Name:YOO
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:DR
Other - First Name:ETHAN
Other - Middle Name:JAE-YOUNG
Other - Last Name:YOO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MSD
Mailing Address - Street 1:14021 MIDLAND RD
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3959
Mailing Address - Country:US
Mailing Address - Phone:858-883-4860
Mailing Address - Fax:858-883-4845
Practice Address - Street 1:14021 MIDLAND RD
Practice Address - Street 2:
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-3959
Practice Address - Country:US
Practice Address - Phone:858-883-4860
Practice Address - Fax:858-883-4845
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002033571223X0400X
CA1036171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics