Healthcare Provider Details

I. General information

NPI: 1730100561
Provider Name (Legal Business Name): ROBERT LOYD JUNG I DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22400 BARTON RD 8
GRAND TERRACE CA
92313-5030
US

IV. Provider business mailing address

22400 BARTON RD 8
GRAND TERRACE CA
92313-5030
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7770
  • Fax: 909-825-7781
Mailing address:
  • Phone: 909-825-7770
  • Fax: 909-825-7781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number27895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: