Provider Demographics
NPI:1376938522
Name:CHUNG, ERIC
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4249 W MCFARLANE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4019
Mailing Address - Country:US
Mailing Address - Phone:818-645-2550
Mailing Address - Fax:
Practice Address - Street 1:14600 SHERMAN WAY STE 260
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2285
Practice Address - Country:US
Practice Address - Phone:818-780-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2024-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040613122300000X
CA197411204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist