Provider Demographics
NPI:1659792927
Name:JUNG, SONG WOO (DDS)
Entity Type:Individual
Prefix:
First Name:SONG WOO
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 1:24642 VESTA
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4718
Mailing Address - Country:US
Mailing Address - Phone:312-533-6386
Mailing Address - Fax:
Practice Address - Street 1:434 S EUCLID ST # 100
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-1247
Practice Address - Country:US
Practice Address - Phone:714-533-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA631851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice