Provider Demographics
NPI:1508542507
Name:CHUNG, GABRIELLA (DMD)
Entity Type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7700 DENROCK AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-1163
Mailing Address - Country:US
Mailing Address - Phone:424-288-6729
Mailing Address - Fax:
Practice Address - Street 1:1171 CRESTON RD STE 107
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3031
Practice Address - Country:US
Practice Address - Phone:805-202-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPENDING122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA109038OtherDENTAL LICENSE