Provider Demographics
NPI:1699505511
Name:WISDOM DENTAL LA
Entity type:Organization
Organization Name:WISDOM DENTAL LA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:YUNG CHUN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:909-548-1356
Mailing Address - Street 1:12453 ROYAL OAKS DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-8824
Mailing Address - Country:US
Mailing Address - Phone:909-548-1356
Mailing Address - Fax:
Practice Address - Street 1:5255 POMONA BLVD STE 12
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90022-1774
Practice Address - Country:US
Practice Address - Phone:323-728-9008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-05
Last Update Date:2024-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty