Provider Demographics
NPI:1396364006
Name:CHUNG, NICHOLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
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 1:10640 SATORI LN APT 364
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8094
Mailing Address - Country:US
Mailing Address - Phone:407-865-2080
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR RM D1-17
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-6405
Practice Address - Country:US
Practice Address - Phone:352-273-5440
Practice Address - Fax:352-273-5446
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN249291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty