Provider Demographics
NPI:1750700456
Name:SAE-UNG, UBONWAN (DDS)
Entity type:Individual
Prefix:DR
First Name:UBONWAN
Middle Name:
Last Name:SAE-UNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JJ
Other - Middle Name:
Other - Last Name:SAE-UNG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:430 N LARCH ST STE 6
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-1283
Mailing Address - Country:US
Mailing Address - Phone:517-574-7935
Mailing Address - Fax:517-485-2944
Practice Address - Street 1:290 N WAYTE LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2124
Practice Address - Country:US
Practice Address - Phone:559-459-5725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI29010212031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1750700456Medicaid