Provider Demographics
NPI:1528180718
Name:CHU, JACQUELYN KWONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:KWONG
Last Name:CHU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32905 W TWELVE MILE RD
Mailing Address - Street 2:SUITE #350
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334
Mailing Address - Country:US
Mailing Address - Phone:248-489-7008
Mailing Address - Fax:248-489-7038
Practice Address - Street 1:32905 W TWELVE MILE RD
Practice Address - Street 2:SUITE #350
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-489-7008
Practice Address - Fax:248-489-7038
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010153371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice