Provider Demographics
NPI:1457404592
Name:JEANNIE CHUNG, DDS, MS, INC
Entity Type:Organization
Organization Name:JEANNIE CHUNG, DDS, MS, INC
Other - Org Name:RONALD K. FUJITAKI, DDS, MS
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHUNG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-794-9954
Mailing Address - Street 1:39055 HASTINGS ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1518
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39055 HASTINGS ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1518
Practice Address - Country:US
Practice Address - Phone:510-794-9954
Practice Address - Fax:510-794-1796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-20
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA382841223P0300X
CA375381223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty