Provider Demographics
NPI:1306277892
Name:EVERGREEN PROSTHODONTIC ASSOCIATES, LLC
Entity type:Organization
Organization Name:EVERGREEN PROSTHODONTIC ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINSUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:YOON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-259-7870
Mailing Address - Street 1:1300 POST RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6038
Mailing Address - Country:US
Mailing Address - Phone:203-259-7870
Mailing Address - Fax:
Practice Address - Street 1:1300 POST RD
Practice Address - Street 2:SUITE 101
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6038
Practice Address - Country:US
Practice Address - Phone:203-259-7870
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN PROSRTHODONTIC ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-09
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96011223P0700X
CT98631223P0700X
1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty