Provider Demographics
NPI:1619711629
Name:SUR, MIN JUNG
Entity type:Individual
Prefix:
First Name:MIN JUNG
Middle Name:
Last Name:SUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10911 NORWICH AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-2164
Mailing Address - Country:US
Mailing Address - Phone:720-534-9057
Mailing Address - Fax:
Practice Address - Street 1:101 SEAGRAVES RD
Practice Address - Street 2:
Practice Address - City:BROWNFIELD
Practice Address - State:TX
Practice Address - Zip Code:79316-5447
Practice Address - Country:US
Practice Address - Phone:806-636-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX406591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice