Healthcare Provider Details

I. General information

NPI: 1134439417
Provider Name (Legal Business Name): KEW GARDENS FAMILY DENTAL,PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 82ND AVENUE
KEW GARDENS NY
11415-1423
US

IV. Provider business mailing address

103 82ND AVE
KEW GARDENS NY
11415-1423
US

V. Phone/Fax

Practice location:
  • Phone: 718-261-2065
  • Fax:
Mailing address:
  • Phone: 718-261-2065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number050329
License Number StateNY

VIII. Authorized Official

Name: DR. AMBER T CHU
Title or Position: OWNER
Credential:
Phone: 718-261-2065