Healthcare Provider Details

I. General information

NPI: 1912596313
Provider Name (Legal Business Name): ELISE MARIKO HEI-FUNG CHENG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 US HIGHWAY 98 N UNIT 105
LAKELAND FL
33809-3863
US

IV. Provider business mailing address

2970 SADDLE RIDGE LN
LAKELAND FL
33810-2533
US

V. Phone/Fax

Practice location:
  • Phone: 863-225-4585
  • Fax:
Mailing address:
  • Phone: 213-986-6848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN25599
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN25599
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: