Provider Demographics
NPI:1063567352
Name:PUNG, IAN KILIONA (DDS)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:KILIONA
Last Name:PUNG
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 1:255 N GILBERT ST
Mailing Address - Street 2:BLDG. C, SUITE 4
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4066
Mailing Address - Country:US
Mailing Address - Phone:951-766-7864
Mailing Address - Fax:951-766-7864
Practice Address - Street 1:255 N GILBERT ST
Practice Address - Street 2:BLDG. C, SUITE 4
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-4066
Practice Address - Country:US
Practice Address - Phone:951-766-7864
Practice Address - Fax:951-766-7864
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA373651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice