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General NPI Number Information
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NPI Number | 1518747765
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Entity Type | Organization
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Legal Business Name | ELITE DENTAL GROUP CANON CITY INC
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Dates
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Enumeration Date | 10/04/2023
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Last Update Date | 11/15/2023
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Provider Practice Location Address
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Address Line | 1215 N 15TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4620
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Country | US
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Telephone | 719-275-5933
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Fax |
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Provider Business Mailing Address
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Address Line | 1215 N 15TH ST
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City | CANON CITY
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State | CO
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Zip | 81212-4620
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | DR. KYU HYUK JUNG
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Credential | DDS
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Telephone | 719-275-5933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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