Healthcare Provider Details

I. General information

NPI: 1932268018
Provider Name (Legal Business Name): JACK JEUN CHEUNG TSE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 12/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 ROBINSON AVE
NEWBURGH NY
12550
US

IV. Provider business mailing address

430 ROBINSON AVE
NEWBURGH NY
12550
US

V. Phone/Fax

Practice location:
  • Phone: 845-561-7255
  • Fax: 845-561-5522
Mailing address:
  • Phone: 845-561-7255
  • Fax: 845-561-5522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number040109
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number10869
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: