Provider Demographics
NPI:1619015815
Name:HWANG, CHUNG-LONG (DDS, PS)
Entity Type:Individual
Prefix:DR
First Name:CHUNG-LONG
Middle Name:
Last Name:HWANG
Suffix:
Gender:M
Credentials:DDS, PS
Other - Prefix:DR
Other - First Name:BRAD
Other - Middle Name:
Other - Last Name:HWANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS, PS
Mailing Address - Street 1:24837 104TH AVE SE STE 200
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-6800
Mailing Address - Country:US
Mailing Address - Phone:253-850-1234
Mailing Address - Fax:253-850-8393
Practice Address - Street 1:24837 104TH AVE SE STE 200
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-6800
Practice Address - Country:US
Practice Address - Phone:253-850-1234
Practice Address - Fax:253-850-8393
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000072991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA884515OtherUNITED CONCORDIA #
WA5019484Medicaid