Provider Demographics
NPI:1104125202
Name:BAE, EUNJOO (DDS)
Entity type:Individual
Prefix:DR
First Name:EUNJOO
Middle Name:
Last Name:BAE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3120 OAK HAMPTON WAY
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-5856
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3840 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-5031
Practice Address - Country:US
Practice Address - Phone:770-670-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014224122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist