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General NPI Number Information
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NPI Number | 1902528672
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Entity Type | Organization
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Legal Business Name | NICOLE CHUNG DMD ENDODONTIC DENTAL PRACTICE
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Dates
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Enumeration Date | 09/19/2022
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Last Update Date | 09/19/2022
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Provider Practice Location Address
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Address Line | 143 S MASON ST
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City | ARROYO GRANDE
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State | CA
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Zip | 93420-3312
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Country | US
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Telephone | 909-913-3429
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Fax |
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Provider Business Mailing Address
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Address Line | 830 TARRAGON LN
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-7264
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Country | US
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Telephone | 909-913-3429
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Fax |
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Authorized Official
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Title or Position | CEO/OWNER
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Name | NICOLE CHUNG
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Credential | DMD
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Telephone | 909-913-3429
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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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