=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841878071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIE CHEUNG
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2021
-----------------------------------------------------
Last Update Date | 03/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4279 78TH ST
-----------------------------------------------------
City | ELMHURST
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11373-2953
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-651-2768
-----------------------------------------------------
Fax | 718-651-2788
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 E 210TH ST
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10467-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 062886
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------