Provider Demographics
NPI:1134104052
Name:SHUNG, SIMON (DMD)
Entity type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:SHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 TWIN GABLES
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-3507
Mailing Address - Country:US
Mailing Address - Phone:412-736-4645
Mailing Address - Fax:
Practice Address - Street 1:6246 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620-2103
Practice Address - Country:US
Practice Address - Phone:949-264-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0362051223G0001X
CA602401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice