Provider Demographics
NPI:1154525590
Name:CARLOS R CHONG A PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:CARLOS R CHONG A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:ROBERTO
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-634-7980
Mailing Address - Street 1:169 SAXONY RD STE 110
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-6779
Mailing Address - Country:US
Mailing Address - Phone:760-634-7980
Mailing Address - Fax:760-634-7982
Practice Address - Street 1:169 SAXONY RD STE 110
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-6779
Practice Address - Country:US
Practice Address - Phone:760-634-7980
Practice Address - Fax:760-634-7982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42640261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental