Healthcare Provider Details

I. General information

NPI: 1053786814
Provider Name (Legal Business Name): JIYEON CHUNG DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 12/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 N CENTRAL AVE STE 420
HARTSDALE NY
10530-1842
US

IV. Provider business mailing address

280 N CENTRAL AVE STE 420
HARTSDALE NY
10530-1842
US

V. Phone/Fax

Practice location:
  • Phone: 914-714-4828
  • Fax:
Mailing address:
  • Phone: 914-714-4828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number051945
License Number StateNY

VIII. Authorized Official

Name: DR. JIYEON CHUNG
Title or Position: DR
Credential: DDS, MS
Phone: 914-714-4828