Provider Demographics
NPI:1659404077
Name:WALTER J. JUNG PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:WALTER J. JUNG PROFESSIONAL DENTAL CORPORATION
Other - Org Name:SOUTHERN LOUISIANA ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:J
Authorized Official - Last Name:JUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PC
Authorized Official - Phone:225-767-7212
Mailing Address - Street 1:8680 BLUEBONNET BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-7825
Mailing Address - Country:US
Mailing Address - Phone:225-767-7212
Mailing Address - Fax:225-767-0945
Practice Address - Street 1:8680 BLUEBONNET BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-7825
Practice Address - Country:US
Practice Address - Phone:225-767-7212
Practice Address - Fax:225-767-0945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA52951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty