Provider Demographics
NPI:1043278153
Name:CHUNG, JAE WOO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAE WOO
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 STRAW FLOWER
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1211
Mailing Address - Country:US
Mailing Address - Phone:714-980-0967
Mailing Address - Fax:
Practice Address - Street 1:27 STRAW FLOWER
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-1211
Practice Address - Country:US
Practice Address - Phone:714-980-0967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0092241223P0300X
CA531221223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC9367360OtherFEDERAL DEA