Healthcare Provider Details

I. General information

NPI: 1699113050
Provider Name (Legal Business Name): CHANOOK AHN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 WILSHIRE BLVD
LOS ANGELES CA
90017-3901
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 213-481-0664
  • Fax:
Mailing address:
  • Phone: 608-354-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number101227
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: