Provider Demographics
NPI:1639561152
Name:CHAMMAE, WAJIH
Entity Type:Individual
Prefix:
First Name:WAJIH
Middle Name:
Last Name:CHAMMAE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 41ST ST APT 1B
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3517
Mailing Address - Country:US
Mailing Address - Phone:909-263-3074
Mailing Address - Fax:
Practice Address - Street 1:3242 41ST ST APT 1B
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3517
Practice Address - Country:US
Practice Address - Phone:909-263-3074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-19
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT113691223G0001X
IL0190304441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program