Provider Demographics
NPI:1780195933
Name:CHUNG, SANG HOON (DMD)
Entity Type:Individual
Prefix:
First Name:SANG
Middle Name:HOON
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:TIM
Other - Middle Name:
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:6265 PANGEA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-5465
Mailing Address - Country:US
Mailing Address - Phone:206-909-5831
Mailing Address - Fax:
Practice Address - Street 1:1591 GRIFFIN ROAD
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278-0000
Practice Address - Country:US
Practice Address - Phone:760-830-7054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE607759071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADE60775907OtherDENTIST LICENSE