Provider Demographics
NPI:1073174074
Name:JUNG, BOLBO (DMD)
Entity Type:Individual
Prefix:
First Name:BOLBO
Middle Name:
Last Name:JUNG
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 1:3107 NJ-38
Mailing Address - Street 2:#2
Mailing Address - City:MOUNT LAUREL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08054
Mailing Address - Country:US
Mailing Address - Phone:856-778-0800
Mailing Address - Fax:
Practice Address - Street 1:3107 NJ-38
Practice Address - Street 2:#2
Practice Address - City:MOUNT LAUREL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08054-0805
Practice Address - Country:US
Practice Address - Phone:856-778-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI028520001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program