Healthcare Provider Details

I. General information

NPI: 1831295567
Provider Name (Legal Business Name): HAESIN S JUNG DDS PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 05/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 EAST MAIN ST
MIDDLETOWN NY
10940
US

IV. Provider business mailing address

465 EAST MAIN ST
MIDDLETOWN NY
10940
US

V. Phone/Fax

Practice location:
  • Phone: 845-343-8212
  • Fax: 845-343-8222
Mailing address:
  • Phone: 845-343-8212
  • Fax: 845-343-8222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number047545
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: