Provider Demographics
NPI:1023780301
Name:MA, JAE JOON (DDS)
Entity type:Individual
Prefix:DR
First Name:JAE JOON
Middle Name:
Last Name:MA
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 1:515 RIVERSIDE DRIVE WEST
Mailing Address - Street 2:#1306
Mailing Address - City:WINDSOR
Mailing Address - State:ON
Mailing Address - Zip Code:N9A 7C3
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26113 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1147
Practice Address - Country:US
Practice Address - Phone:586-393-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601091122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist