Provider Demographics
NPI:1154762599
Name:SOETANTO, JUN (DMD)
Entity type:Individual
Prefix:DR
First Name:JUN
Middle Name:
Last Name:SOETANTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 SHAKER BLVD
Mailing Address - Street 2:SUITE 136
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44104-3869
Mailing Address - Country:US
Mailing Address - Phone:216-368-7238
Mailing Address - Fax:
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:SUITE 136
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3869
Practice Address - Country:US
Practice Address - Phone:216-368-7238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES 33.79122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist