Healthcare Provider Details

I. General information

NPI: 1629239132
Provider Name (Legal Business Name): SOONG-RYONG JUNG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1910 PACKARD ST STE B
ANN ARBOR MI
48104-4734
US

IV. Provider business mailing address

4478 LAKE FOREST DR E
ANN ARBOR MI
48108-9684
US

V. Phone/Fax

Practice location:
  • Phone: 734-478-7311
  • Fax:
Mailing address:
  • Phone: 734-214-0829
  • Fax: 313-576-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2901019627
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901019627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: