Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0300X | Periodontist | 53122 | CA |
N | 1223P0300X | Periodontist | D009224 | AZ |
NPI | 1043278153 |
---|---|
Provider Name | Dr. Jae Woo Chung |
First Address | Irvine, CA 92620-1211 |
Second Address | Irvine, CA 92620-1211 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2006 |
Last Update Date | 26/02/2020 |