Provider Demographics
NPI:1194807750
Name:CHUNG, CHOON (DDS)
Entity type:Individual
Prefix:
First Name:CHOON
Middle Name:
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 1:117 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ASHLEY
Mailing Address - State:PA
Mailing Address - Zip Code:18706-2323
Mailing Address - Country:US
Mailing Address - Phone:570-824-1009
Mailing Address - Fax:570-824-1037
Practice Address - Street 1:117 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ASHLEY
Practice Address - State:PA
Practice Address - Zip Code:18706-2323
Practice Address - Country:US
Practice Address - Phone:570-824-1009
Practice Address - Fax:570-824-1037
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS036908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000000302709OtherDENTAL BENEFIT PROVIDERS
PA1016338340001Medicaid
PA9183596OtherDORAL DENTAL