Healthcare Provider Details

I. General information

NPI: 1164902664
Provider Name (Legal Business Name): JEFFERY CHEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-5318
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

V. Phone/Fax

Practice location:
  • Phone: 702-787-8240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS041728
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDS041728
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number12406
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: