Provider Demographics
NPI:1235380999
Name:CHUNG, ILLNAHM (DMD)
Entity Type:Individual
Prefix:
First Name:ILLNAHM
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 1:8224 VIA VERONA
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32836-7700
Mailing Address - Country:US
Mailing Address - Phone:321-279-4633
Mailing Address - Fax:
Practice Address - Street 1:2102 E OSCEOLA PKWY STE 21022104
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34743-8630
Practice Address - Country:US
Practice Address - Phone:407-201-3998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist