Provider Demographics
NPI:1679146823
Name:AHN, BRYAN BOUNGJUN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:BOUNGJUN
Last Name:AHN
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 1:15 SAGAMORE LN UNIT 309
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-3850
Mailing Address - Country:US
Mailing Address - Phone:857-769-8969
Mailing Address - Fax:
Practice Address - Street 1:1025 W AVENUE K STE 105
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6429
Practice Address - Country:US
Practice Address - Phone:661-723-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-23
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT132211223G0001X
CA111424122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice