Provider Demographics
NPI:1437305455
Name:DR.CHARLES C JENG/DR.MARTHA Z YAN
Entity Type:Organization
Organization Name:DR.CHARLES C JENG/DR.MARTHA Z YAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-ONWER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:Z
Authorized Official - Last Name:YAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-829-1559
Mailing Address - Street 1:3011 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2555
Mailing Address - Country:US
Mailing Address - Phone:310-829-1559
Mailing Address - Fax:310-828-7383
Practice Address - Street 1:3011 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2555
Practice Address - Country:US
Practice Address - Phone:310-829-1559
Practice Address - Fax:310-828-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-10
Last Update Date:2008-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50021122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty