MEDICARE: CHI FUNG IP DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DI20939	NJ

General Provider Information

NPI Number	:	1114905452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHI FUNG IP DMD

Provider Business Mailing Address
First Line	:	804 CLINTON AVE
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07108
Country	:	US
Telephone Number	:	973-374-5200
Fax Number	:	973-374-5609

Provider Business Practice Location Address
First Line	:	804 CLINTON AVE
Second Line	:	CLINTON HILL DENTAL ASSOC
City	:	NEWARK
State	:	NJ
Zip	:	07108
Country	:	US
Telephone Number	:	973-374-5200
Fax Number	:	973-374-5609

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2006
Last Update Date	:	07/08/2007

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