Provider Demographics
NPI:1154707370
Name:CHUNG, BUM MO (DMD)
Entity type:Individual
Prefix:DR
First Name:BUM
Middle Name:MO
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 SUWANEE EAST DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-1404
Mailing Address - Country:US
Mailing Address - Phone:404-642-0888
Mailing Address - Fax:
Practice Address - Street 1:1040 GARLAND DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-3201
Practice Address - Country:US
Practice Address - Phone:770-725-7377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015032122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist