Healthcare Provider Details

I. General information

NPI: 1013350727
Provider Name (Legal Business Name): AILEEN DENG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 07/01/2022
Certification Date: 07/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 MEDICAL PARK RD STE 101
MOORESVILLE NC
28117-8541
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-7070
  • Fax: 980-302-7075
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License Number2019-00612
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2019-00612
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number2019-00612
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: