Healthcare Provider Details

I. General information

NPI: 1184865370
Provider Name (Legal Business Name): LORA CHONGRUK DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 01/11/2026
Certification Date: 01/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 475 BOX 1
FPO AP
96350-1200
US

IV. Provider business mailing address

PSC 475 BOX 1
FPO AP
96350-1200
US

V. Phone/Fax

Practice location:
  • Phone: 315-243-3546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDE60100287
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021.002294
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: