=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649817404
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNG AHN DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2019
-----------------------------------------------------
Last Update Date | 07/06/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1490 E FOOTHILL BLVD STE B
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-256-4457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1490 E FOOTHILL BLVD STE B
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-4072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-256-4457
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. SUNG MIN AHN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-256-4457
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------