Provider Demographics
NPI:1073061743
Name:CHA, JIEUN (DMD)
Entity Type:Individual
Prefix:
First Name:JIEUN
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 FELLSWAY
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4959
Mailing Address - Country:US
Mailing Address - Phone:781-306-9644
Mailing Address - Fax:
Practice Address - Street 1:616 FELLSWAY
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4959
Practice Address - Country:US
Practice Address - Phone:781-306-9644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist