Provider Demographics
NPI:1275362857
Name:CHUNG, BETHANY
Entity type:Individual
Prefix:DR
First Name:BETHANY
Middle Name:
Last Name:CHUNG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5099 WRIGHT DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-3020
Mailing Address - Country:US
Mailing Address - Phone:248-686-6785
Mailing Address - Fax:
Practice Address - Street 1:322 E EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-3011
Practice Address - Country:US
Practice Address - Phone:989-723-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016020371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice