=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649775040
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES L. CHENG DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2018
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 W 136TH AVE STE 136
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80023-9308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-586-6846
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 238 MAIN STREET
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-466-2231
-----------------------------------------------------
Fax | 770-466-2232
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 00204702
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 11007
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------