Provider Demographics
NPI:1871233296
Name:CHUNG, TIFFANY (DDS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-2010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1600 S EAST RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2610
Practice Address - Country:US
Practice Address - Phone:860-676-0050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPENDING1223G0001X
NY261QS1000X
390200000X
CT13517122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program