Healthcare Provider Details

I. General information

NPI: 1457404592
Provider Name (Legal Business Name): JEANNIE CHUNG, DDS, MS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39055 HASTINGS ST SUITE 104
FREMONT CA
94538-1518
US

IV. Provider business mailing address

39055 HASTINGS ST SUITE 104
FREMONT CA
94538-1518
US

V. Phone/Fax

Practice location:
  • Phone: 510-794-9954
  • Fax: 510-794-1796
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number38284
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number37538
License Number StateCA

VIII. Authorized Official

Name: JEANNIE CHUNG
Title or Position: PRESIDENT
Credential: DDS
Phone: 510-794-9954