Provider Demographics
NPI:1578233557
Name:JI, SOMYUNG (DDS)
Entity type:Individual
Prefix:DR
First Name:SOMYUNG
Middle Name:
Last Name:JI
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 1:714 TIVERTON AVE RM 10-165
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8361
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5515 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2066
Practice Address - Country:US
Practice Address - Phone:951-352-5838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-20
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1069671223G0001X, 1223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
No1223G0001XDental ProvidersDentistGeneral Practice