Healthcare Provider Details

I. General information

NPI: 1740704394
Provider Name (Legal Business Name): JIAKUN CHENG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 07/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 28038
APO AE
09112-8038
US

IV. Provider business mailing address

UNIT 28038
APO AE
09112-8038
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401415651
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: