Provider Demographics
NPI:1831295567
Name:JUNG, HAESIN S (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:HAESIN
Middle Name:S
Last Name:JUNG
Suffix:
Gender:F
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10940
Mailing Address - Country:US
Mailing Address - Phone:845-343-8212
Mailing Address - Fax:845-343-8222
Practice Address - Street 1:465 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940
Practice Address - Country:US
Practice Address - Phone:845-343-8212
Practice Address - Fax:845-343-8222
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0475451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02591495Medicaid
NY02591495Medicaid