Provider Demographics
NPI:1508433798
Name:SUNG, JAMIE JISOO
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:JISOO
Last Name:SUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MCDONALD PL UNIT 304
Mailing Address - Street 2:
Mailing Address - City:GOLETA
Mailing Address - State:CA
Mailing Address - Zip Code:93117-2390
Mailing Address - Country:US
Mailing Address - Phone:949-522-1763
Mailing Address - Fax:
Practice Address - Street 1:5680 CALLE REAL
Practice Address - Street 2:
Practice Address - City:GOLETA
Practice Address - State:CA
Practice Address - Zip Code:93117-2317
Practice Address - Country:US
Practice Address - Phone:805-979-3037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-07
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA390200000X
CA1078851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program