Provider Demographics
NPI:1871932624
Name:CHUNG, LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:
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 1:7431 NW LOOP 410 STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-3597
Mailing Address - Country:US
Mailing Address - Phone:210-680-0553
Mailing Address - Fax:
Practice Address - Street 1:7431 NW LOOP 410 STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-3597
Practice Address - Country:US
Practice Address - Phone:210-680-0553
Practice Address - Fax:210-680-0593
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX290761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX331400702Medicaid