Healthcare Provider Details

I. General information

NPI: 1396364006
Provider Name (Legal Business Name): NICHOLAS CHUNG DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MORSE BLVD STE 102
WINTER PARK FL
32789-4259
US

IV. Provider business mailing address

1305 MORGAN STANLEY AVE UNIT 516
WINTER PARK FL
32789-1977
US

V. Phone/Fax

Practice location:
  • Phone: 407-644-4463
  • Fax:
Mailing address:
  • Phone: 407-865-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN24929
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: