Basic Information
| Provider Information | |||||||||
| NPI: | 1023597333 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | HEEJIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1631 WETZEL AVE BLDG 815 | ||||||||
| Address2: | |||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134095 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 170 INNER LOOP ROAD | ||||||||
| Address2: | |||||||||
| City: | FORT IRWIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195265537 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2018 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 103033 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.