Provider Demographics
NPI:1063592061
Name:CHUNG, HENRY CHARLES (DDS)
Entity type:Individual
Prefix:DR
First Name:HENRY
Middle Name:CHARLES
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 1:1144 S WESTERN AVE
Mailing Address - Street 2:#210
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2376
Mailing Address - Country:US
Mailing Address - Phone:323-373-0073
Mailing Address - Fax:323-373-0066
Practice Address - Street 1:1144 S WESTERN AVE
Practice Address - Street 2:#210
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2376
Practice Address - Country:US
Practice Address - Phone:323-373-0073
Practice Address - Fax:323-373-0066
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA269711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9360901OtherMEDICAL