Provider Demographics
NPI:1497967566
Name:CHUNG, TAE SUB (DDS)
Entity Type:Individual
Prefix:MR
First Name:TAE SUB
Middle Name:
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 1:15622 S CRENSHAW BLVD
Mailing Address - Street 2:STE B
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4528
Mailing Address - Country:US
Mailing Address - Phone:310-323-9922
Mailing Address - Fax:310-515-3551
Practice Address - Street 1:15622 S CRENSHAW BLVD
Practice Address - Street 2:STE B
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4528
Practice Address - Country:US
Practice Address - Phone:310-323-9922
Practice Address - Fax:310-515-3551
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26363122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2636301OtherDENTICAL