Provider Demographics
NPI:1154795656
Name:CHUNG, MICHAEL (DDS, MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 E LAS TUNAS DR STE 206
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-5514
Mailing Address - Country:US
Mailing Address - Phone:818-780-2062
Mailing Address - Fax:
Practice Address - Street 1:360 E LAS TUNAS DR STE 206
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-5514
Practice Address - Country:US
Practice Address - Phone:818-768-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-20
Last Update Date:2020-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64034122300000X, 1223S0112X
CA64035204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery