Provider Demographics
NPI:1487290144
Name:CHUNG, JAE KUL (DDS)
Entity type:Individual
Prefix:
First Name:JAE
Middle Name:KUL
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 1:25581 LANE ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2412
Mailing Address - Country:US
Mailing Address - Phone:828-768-3606
Mailing Address - Fax:
Practice Address - Street 1:61325 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-1912
Practice Address - Country:US
Practice Address - Phone:760-366-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1042591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice