Provider Demographics
NPI:1215112362
Name:CHUNG, BRYAN HYUNG (DMD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:HYUNG
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 1:266 S. HARVARD BLVD STE110
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-4374
Mailing Address - Country:US
Mailing Address - Phone:213-380-2727
Mailing Address - Fax:
Practice Address - Street 1:266 S. HARVARD BLVD STE 110
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-4374
Practice Address - Country:US
Practice Address - Phone:213-380-2727
Practice Address - Fax:213-380-2822
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50588122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist