Provider Demographics
NPI:1376938522
Name:CHUNG, ERIC
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 LOCUST ST
Mailing Address - Street 2:UNIT 8B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3834
Mailing Address - Country:US
Mailing Address - Phone:818-645-2550
Mailing Address - Fax:
Practice Address - Street 1:1425 LOCUST ST
Practice Address - Street 2:APT 8B
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3832
Practice Address - Country:US
Practice Address - Phone:818-645-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS040613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program