Healthcare Provider Details

I. General information

NPI: 1487562914
Provider Name (Legal Business Name): CHANOOK D AHN DMD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 AIRWAY AVE STE F103
COSTA MESA CA
92626-4651
US

IV. Provider business mailing address

3151 AIRWAY AVE STE F103
COSTA MESA CA
92626-4651
US

V. Phone/Fax

Practice location:
  • Phone: 714-549-7030
  • Fax:
Mailing address:
  • Phone: 608-354-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: CHANOOK D AHN
Title or Position: OWNER
Credential: DMD
Phone: 608-354-7113