Provider Demographics
NPI:1255438172
Name:CHONG, CAROLYN MARIE (DDS, MS)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:CHONG
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2850 TELEGRAPH AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1192
Mailing Address - Country:US
Mailing Address - Phone:510-841-6357
Mailing Address - Fax:510-841-8566
Practice Address - Street 1:2850 TELEGRAPH AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1192
Practice Address - Country:US
Practice Address - Phone:510-841-6357
Practice Address - Fax:510-841-8566
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476021223E0200X
HIDT-20011223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics