=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871928150
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KI Y CHUNG D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2013
-----------------------------------------------------
Last Update Date | 07/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9910 TRACY LOOP W3ZS USA DENTAC FT BELVOI
-----------------------------------------------------
City | FT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-455-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9910 TRACY LOOP W3ZS USA DENTAC FT BELVOI
-----------------------------------------------------
City | FT BELVOIR
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22060-5443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-455-5574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-4528
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------