Provider Demographics
NPI:1962899484
Name:CHUNG, SUSAN LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:LEE
Last Name:CHUNG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10969 PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-6892
Mailing Address - Country:US
Mailing Address - Phone:254-715-4830
Mailing Address - Fax:
Practice Address - Street 1:12455 VICTORIA GARDENS LN
Practice Address - Street 2:SUITE 190
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-7530
Practice Address - Country:US
Practice Address - Phone:909-646-3057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist