Provider Demographics
NPI:1225010549
Name:YOO, JAESUK
Entity type:Individual
Prefix:
First Name:JAESUK
Middle Name:
Last Name:YOO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 RIDGELEA DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-3231
Mailing Address - Country:US
Mailing Address - Phone:253-455-8656
Mailing Address - Fax:
Practice Address - Street 1:1065 W. PERIMETER RD
Practice Address - Street 2:316 DS
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762
Practice Address - Country:US
Practice Address - Phone:402-612-2544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice