Provider Demographics
NPI:1235622762
Name:CHUNG, CHEOLWON (DMD)
Entity Type:Individual
Prefix:
First Name:CHEOLWON
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 1:4800 ALLENDALE RD APT 1423
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77017-5480
Mailing Address - Country:US
Mailing Address - Phone:832-638-9428
Mailing Address - Fax:
Practice Address - Street 1:2631 FAUDREE RD STE B
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8530
Practice Address - Country:US
Practice Address - Phone:432-339-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-09
Last Update Date:2018-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice