Provider Demographics
NPI:1720128093
Name:CHUNG, DANIEL T (DDS)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:T
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 1:1809 VERDUGO BLVD
Mailing Address - Street 2:SUITE# 340
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-1402
Mailing Address - Country:US
Mailing Address - Phone:818-952-9011
Mailing Address - Fax:818-952-9014
Practice Address - Street 1:1809 VERDUGO BLVD
Practice Address - Street 2:SUITE# 340
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91208-1402
Practice Address - Country:US
Practice Address - Phone:818-952-9011
Practice Address - Fax:818-952-9014
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954646984OtherTAX ID