Basic Information
| Provider Information | |||||||||
| NPI: | 1336499326 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHUNG | ||||||||
| FirstName: | JOHANNA | ||||||||
| MiddleName: | |||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH STREET | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 959 MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955011219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074427078 | ||||||||
| FaxNumber: | 7074427298 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 12/03/2012 | ||||||||
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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 | 122300000X | 61910 | CA | Y | Dental Providers | Dentist |
No ID Information.