Provider Demographics
NPI:1992859862
Name:BAE, ANDREW CHUNGSUP (DDS)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:CHUNGSUP
Last Name:BAE
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 1:422 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2861
Mailing Address - Country:US
Mailing Address - Phone:201-585-1669
Mailing Address - Fax:201-585-2315
Practice Address - Street 1:422 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2861
Practice Address - Country:US
Practice Address - Phone:201-585-1669
Practice Address - Fax:201-585-2315
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02256500122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist