Provider Demographics
NPI:1770986481
Name:HWANG, SUNGJUN
Entity type:Individual
Prefix:
First Name:SUNGJUN
Middle Name:
Last Name:HWANG
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 1:3670 BRIDGEPORT WAY W
Mailing Address - Street 2:UNIT B
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4413
Mailing Address - Country:US
Mailing Address - Phone:253-212-3430
Mailing Address - Fax:253-212-3288
Practice Address - Street 1:3670 BRIDGEPORT WAY W
Practice Address - Street 2:UNIT B
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4413
Practice Address - Country:US
Practice Address - Phone:253-212-3430
Practice Address - Fax:253-212-3288
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60450555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA49235DMMedicaid
WA49235DMMedicaid