Healthcare Provider Details

I. General information

NPI: 1558524454
Provider Name (Legal Business Name): JING CHEN DDS, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W 168TH ST P&S BOX 20, VC9-217
NEW YORK NY
10032-3725
US

IV. Provider business mailing address

630 WEST 168 STREET P&S BOX 20, VC9-217
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-342-1639
  • Fax: 212-305-4609
Mailing address:
  • Phone: 212-342-1639
  • Fax: 212-305-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number000029
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number057123-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: