Provider Demographics
NPI:1114794112
Name:CHUNG, DAEKWON (DMD)
Entity Type:Individual
Prefix:
First Name:DAEKWON
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 1:4940 IRVINE BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1960
Mailing Address - Country:US
Mailing Address - Phone:714-730-0491
Mailing Address - Fax:
Practice Address - Street 1:4940 IRVINE BLVD STE 203
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-1960
Practice Address - Country:US
Practice Address - Phone:714-730-0491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1076011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice