Healthcare Provider Details

I. General information

NPI: 1639465784
Provider Name (Legal Business Name): JER-WEI CHIANG D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 05/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13702 NORTHERN BLVD APT 6C
FLUSHING NY
11354-4322
US

IV. Provider business mailing address

13702 NORTHERN BLVD APT 6C
FLUSHING NY
11354-4322
US

V. Phone/Fax

Practice location:
  • Phone: 310-500-9822
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number057638
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: