Provider Demographics
NPI:1063530509
Name:JOO, ILCHEON (DDS)
Entity type:Individual
Prefix:DR
First Name:ILCHEON
Middle Name:
Last Name:JOO
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 1:6690 HAUSER RD
Mailing Address - Street 2:M101
Mailing Address - City:MACUNGIE
Mailing Address - State:PA
Mailing Address - Zip Code:18062-8102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 MIFFLIN ST
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-1318
Practice Address - Country:US
Practice Address - Phone:570-345-3495
Practice Address - Fax:570-345-3161
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037775122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist