Provider Demographics
NPI:1467878157
Name:JUNG, KYUSE
Entity Type:Individual
Prefix:
First Name:KYUSE
Middle Name:
Last Name:JUNG
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 1:10824 PEPPER WAY
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2500
Mailing Address - Country:US
Mailing Address - Phone:424-202-4985
Mailing Address - Fax:
Practice Address - Street 1:10824 PEPPER WAY
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2500
Practice Address - Country:US
Practice Address - Phone:424-202-4985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-05
Last Update Date:2014-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist