Provider Demographics
NPI:1558983270
Name:CHUNG, CHAN KWON
Entity type:Individual
Prefix:
First Name:CHAN KWON
Middle Name:
Last Name:CHUNG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 CHURCHILL DOWNS WAY
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-3869
Mailing Address - Country:US
Mailing Address - Phone:214-244-7893
Mailing Address - Fax:
Practice Address - Street 1:2502 CHURCHILL DOWNS WAY
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-3869
Practice Address - Country:US
Practice Address - Phone:214-244-7893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-15
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI030660001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics