Provider Demographics
NPI:1871928150
Name:CHUNG, KI Y (DDS)
Entity type:Individual
Prefix:DR
First Name:KI
Middle Name:Y
Last Name:CHUNG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9910 TRACY LOOP
Mailing Address - Street 2:W3ZS USA DENTAC FT BELVOI
Mailing Address - City:FT BELVOIR
Mailing Address - State:VA
Mailing Address - Zip Code:22060-5443
Mailing Address - Country:US
Mailing Address - Phone:562-455-5574
Mailing Address - Fax:
Practice Address - Street 1:9910 TRACY LOOP
Practice Address - Street 2:W3ZS USA DENTAC FT BELVOI
Practice Address - City:FT BELVOIR
Practice Address - State:VA
Practice Address - Zip Code:22060-5443
Practice Address - Country:US
Practice Address - Phone:562-455-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-05
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4528122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist