MEDICARE: JAE YON CHUNG DENTAL INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1245576321
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JAE YON CHUNG DENTAL INC

Provider Business Mailing Address
First Line	:	1075 N WESTERN AVE
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2307
Country	:	US
Telephone Number	:	323-466-4567
Fax Number	:	323-733-0150

Provider Business Practice Location Address
First Line	:	1075 N WESTERN AVE
Second Line	:	SUITE 102
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-2307
Country	:	US
Telephone Number	:	323-466-4567
Fax Number	:	323-733-0150

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JAE Y CHUNG
Credential	:	DMD
Telephone Number	:	323-466-4567

Provider Enumeration Date	:	12/18/2012
Last Update Date	:	02/09/2014

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