Provider Demographics
NPI:1902579949
Name:CHUNG, JAE
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-0213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:654 W 4TH ST # A
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3216
Practice Address - Country:US
Practice Address - Phone:909-386-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS105162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist