Provider Demographics
NPI:1629516539
Name:JUNG, SEUNG MIN
Entity Type:Individual
Prefix:
First Name:SEUNG MIN
Middle Name:
Last Name:JUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PURGIOCITY 1 CHA, 2 JEONGJA RO, BUNDANG GU
Mailing Address - Street 2:APT #2104
Mailing Address - City:SEONGNAM SI
Mailing Address - State:GYUNGGI DO
Mailing Address - Zip Code:13560
Mailing Address - Country:KR
Mailing Address - Phone:82108-819-8070
Mailing Address - Fax:
Practice Address - Street 1:150 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2412
Practice Address - Country:US
Practice Address - Phone:718-920-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMDD4843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program