=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093314239
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NA EUN CHUNG D.M.D. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2020
-----------------------------------------------------
Last Update Date | 09/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3123 W OLYMPIC BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-487-5961
-----------------------------------------------------
Fax | 213-487-5962
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3123 W OLYMPIC BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90006-2462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-487-5961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NA EUN CHUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-308-9413
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------