Provider Demographics
NPI:1568467835
Name:JUNG, TED A (DDS)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:A
Last Name:JUNG
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 1:15954 RIVERS EDGE DR STE 304
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-7894
Mailing Address - Country:US
Mailing Address - Phone:171-563-4254
Mailing Address - Fax:715-598-4881
Practice Address - Street 1:15397 STATE HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WI
Practice Address - Zip Code:54138-9702
Practice Address - Country:US
Practice Address - Phone:715-276-6321
Practice Address - Fax:715-276-1428
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5781-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI337-90800Medicaid
WI337-90800Medicaid