MEDICARE: DR. THERESA CHENG D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	6084	WA
2	1223P0300X	Periodontics	DE00006084	WA

General Provider Information

NPI Number	:	1669475406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THERESA CHENG D.D.S.

Provider Business Mailing Address
First Line	:	22516 SE 64TH PLACE
Second Line	:	#250
City	:	ISSAQUAH
State	:	WA
Zip	:	98027
Country	:	US
Telephone Number	:	425-392-8992
Fax Number	:	425-392-0184

Provider Business Practice Location Address
First Line	:	22516 SE 64TH PLACE
Second Line	:	#250
City	:	ISSAQUAH
State	:	WA
Zip	:	98027
Country	:	US
Telephone Number	:	425-392-8992
Fax Number	:	425-392-0184

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	11/06/2009

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