Provider Demographics
NPI:1366537078
Name:JUNG, TAE KYUNG (DMD)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:KYUNG
Last Name:JUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3502 EXCEL DR
Mailing Address - Street 2:#1
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9136
Mailing Address - Country:US
Mailing Address - Phone:541-690-1656
Mailing Address - Fax:
Practice Address - Street 1:3502 EXCEL DR
Practice Address - Street 2:#1
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-9136
Practice Address - Country:US
Practice Address - Phone:541-690-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8640122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist