Provider Demographics
NPI:1629239132
Name:JUNG, SOONG-RYONG (DDS)
Entity Type:Individual
Prefix:
First Name:SOONG-RYONG
Middle Name:
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 1:4478 LAKE FOREST DR E
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-9684
Mailing Address - Country:US
Mailing Address - Phone:734-214-0829
Mailing Address - Fax:313-576-1129
Practice Address - Street 1:1910 PACKARD ST STE B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4734
Practice Address - Country:US
Practice Address - Phone:734-478-7311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-18
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010196271223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty