=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982009908
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. CHUNG DENTAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2014
-----------------------------------------------------
Last Update Date | 11/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5535 HOLLYWOOD BLVD
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90028-6807
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-488-3712
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5321 1/4 DOCKWEILER PL
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90019-2623
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-488-3712
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MILLIE CHUNG
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 626-488-3712
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60224
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------