Provider Demographics
NPI:1982009908
Name:M. CHUNG DENTAL CORP.
Entity Type:Organization
Organization Name:M. CHUNG DENTAL CORP.
Other - Org Name:BIRDSEYE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:626-488-3712
Mailing Address - Street 1:5321 1/4 DOCKWEILER PL
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-2623
Mailing Address - Country:US
Mailing Address - Phone:626-488-3712
Mailing Address - Fax:
Practice Address - Street 1:5535 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-6807
Practice Address - Country:US
Practice Address - Phone:626-488-3712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA602241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty