Active NPI
Jungsoo Nam
- Dentist
- Bloomington, IN
National Provider Identifier
1194501031
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12014730A
- Practice address
- 330 N Jacob Dr
Bloomington, IN 47404-4823 - Phone
- (812) 323-7595
- NPI assigned
- Sep 6, 2023
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Student in an Organized Health Care Education/Training Program | 390200000X | |||
| Dentist | 122300000X | 12014730A | IN | Primary |
Addresses
Primary practice location
330 N Jacob Dr
Bloomington, IN 47404-4823
Mailing address
1001 Shadow LN
Las Vegas, NV 89106-4124
Other practice location 1
1001 Shadow Ln
Las Vegas, NV 89106-4124
Phone (702) 786-5928
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12014730A | IN | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1693958400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1748476800000",
"number": "1194501031",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1001 SHADOW LN",
"city": "LAS VEGAS",
"state": "NV",
"postal_code": "891064124"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "330 N JACOB DR",
"city": "BLOOMINGTON",
"state": "IN",
"postal_code": "474044823",
"telephone_number": "812-323-7595"
}
],
"practiceLocations": [
{
"address_1": "1001 Shadow Ln",
"address_purpose": "LOCATION",
"city": "Las Vegas",
"state": "NV",
"postal_code": "891064124",
"country_code": "US",
"telephone_number": "702-786-5928",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "NAM",
"first_name": "JUNGSOO",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2023-09-06",
"last_updated": "2025-05-29",
"certification_date": "2025-05-29",
"status": "A"
},
"taxonomies": [
{
"code": "390200000X",
"taxonomy_group": "",
"desc": "Student in an Organized Health Care Education/Training Program",
"state": null,
"license": null,
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IN",
"license": "12014730A",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Bloomington, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 29, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.