Provider Demographics
NPI:1497275697
Name:CHUNG, JUSTIN DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 MIDDLE TPKE W STE 209
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3864
Mailing Address - Country:US
Mailing Address - Phone:860-649-3129
Mailing Address - Fax:
Practice Address - Street 1:483 MIDDLE TPKE W STE 209
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3864
Practice Address - Country:US
Practice Address - Phone:860-649-3129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-20
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT122441223G0001X
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY390200000XMedicaid