Provider Demographics
NPI:1598043549
Name:CHUNG, SO YEON
Entity Type:Individual
Prefix:
First Name:SO
Middle Name:YEON
Last Name:CHUNG
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 1:708 GLEN ABBEY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-1378
Mailing Address - Country:US
Mailing Address - Phone:347-899-5601
Mailing Address - Fax:
Practice Address - Street 1:112 INDUSTRIAL AVE
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020
Practice Address - Country:US
Practice Address - Phone:817-270-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX296451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice