Provider Demographics
NPI:1063909414
Name:JUNG, SUNJAE
Entity type:Individual
Prefix:
First Name:SUNJAE
Middle Name:
Last Name:JUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 TIDEWAY DR APT 215
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3537
Mailing Address - Country:US
Mailing Address - Phone:805-835-5136
Mailing Address - Fax:
Practice Address - Street 1:265 16TH ST, RICHMOND
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801
Practice Address - Country:US
Practice Address - Phone:510-233-6515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist