Provider Demographics
NPI:1649256074
Name:CHUNG, EDWIN
Entity type:Individual
Prefix:
First Name:EDWIN
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 1:6950 NE CAMPUS WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97124-5611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6505 216TH ST SW STE 200
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-6026
Practice Address - Country:US
Practice Address - Phone:855-433-6825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-18
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000099481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice