Provider Demographics
NPI:1699981670
Name:OH, DONG HEON (DDS)
Entity type:Individual
Prefix:
First Name:DONG HEON
Middle Name:
Last Name:OH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W GRAND AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:MONTVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07645-1829
Mailing Address - Country:US
Mailing Address - Phone:201-746-9910
Mailing Address - Fax:201-746-9909
Practice Address - Street 1:305 W GRAND AVE STE 600
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1829
Practice Address - Country:US
Practice Address - Phone:201-746-9910
Practice Address - Fax:201-746-9909
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212901223G0001X
NJ22DI027131001223X0400X
MADN212901223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110072945AMedicaid
MA0205419Medicare ID - Type Unspecified