Provider Demographics
NPI:1740890789
Name:UNG, KELLY
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:UNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15605 FACILIDAD ST
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-5205
Mailing Address - Country:US
Mailing Address - Phone:626-474-7590
Mailing Address - Fax:
Practice Address - Street 1:9050 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-2410
Practice Address - Country:US
Practice Address - Phone:562-731-0470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDA93516126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA5919410Medicaid
CARDA93516Medicaid