Provider Demographics
NPI:1740325430
Name:CHUNG, CHANG KYUN (DDS)
Entity type:Individual
Prefix:DR
First Name:CHANG
Middle Name:KYUN
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3663 W. 6TH ST.
Mailing Address - Street 2:SUITE# 105
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020
Mailing Address - Country:US
Mailing Address - Phone:323-730-8900
Mailing Address - Fax:323-730-1758
Practice Address - Street 1:3663 W. 6TH ST.
Practice Address - Street 2:SUITE #105
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020
Practice Address - Country:US
Practice Address - Phone:323-730-8900
Practice Address - Fax:323-730-1758
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB36530Medicaid