Provider Demographics
NPI:1114379567
Name:CHUNG, JINBO (DMD)
Entity Type:Individual
Prefix:DR
First Name:JINBO
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 1:4623 LAKESIDE DR UNIT 4211
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-8585
Mailing Address - Country:US
Mailing Address - Phone:213-999-1731
Mailing Address - Fax:
Practice Address - Street 1:420 SUPERIOR ST
Practice Address - Street 2:ERIE COUNTY HEALTH DEPARTMENT
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-1849
Practice Address - Country:US
Practice Address - Phone:419-626-5623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.24861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist