Healthcare Provider Details

I. General information

NPI: 1619796802
Provider Name (Legal Business Name): SEUNG AH JUNG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 5TH ST UNIT 587
SACRAMENTO CA
95814-5462
US

IV. Provider business mailing address

1501 5TH ST UNIT 587
SACRAMENTO CA
95814-5462
US

V. Phone/Fax

Practice location:
  • Phone: 734-417-8270
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number107895
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: