Provider Demographics
NPI:1366583015
Name:CHUNG, DANIEL JISUNG (DDS)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JISUNG
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 VICTORIA ST
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-1906
Mailing Address - Country:US
Mailing Address - Phone:949-631-1420
Mailing Address - Fax:949-548-8844
Practice Address - Street 1:275 VICTORIA ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-1906
Practice Address - Country:US
Practice Address - Phone:949-631-1420
Practice Address - Fax:949-548-8844
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA536991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice