Provider Demographics
NPI:1427424076
Name:JEESOMIN
Entity type:Organization
Organization Name:JEESOMIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:NOONE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-866-5123
Mailing Address - Street 1:219 W HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:MYERSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17067-2360
Mailing Address - Country:US
Mailing Address - Phone:717-866-5123
Mailing Address - Fax:
Practice Address - Street 1:219 W HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:MYERSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17067-2360
Practice Address - Country:US
Practice Address - Phone:717-866-5123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029040L1223G0001X
PADS028570L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty