Provider Demographics
NPI:1306968326
Name:OH, SUSAN JIYOUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JIYOUNG
Last Name:OH
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 1:819 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-5030
Mailing Address - Country:US
Mailing Address - Phone:847-245-4709
Mailing Address - Fax:
Practice Address - Street 1:1227 N ILLINOIS 83 #E
Practice Address - Street 2:1227 N STATE 83
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030
Practice Address - Country:US
Practice Address - Phone:847-548-2222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-025715122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist