MEDICARE: LONG K PHUNG DMD

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	DN016140	GA

General Provider Information

NPI Number	:	1982088407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LONG K PHUNG DMD

Provider Business Mailing Address
First Line	:	911 DULUTH HWY STE E2
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-5399
Country	:	US
Telephone Number	:	678-209-2273
Fax Number	:

Provider Business Practice Location Address
First Line	:	911 DULUTH HWY STE E2
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-5399
Country	:	US
Telephone Number	:	678-209-2273
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2015
Last Update Date	:	11/20/2022

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