Provider Demographics
NPI:1669671970
Name:JEONG, CHARLES (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JEONG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14205 ROOSEVELT AVE
Mailing Address - Street 2:134
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6045
Mailing Address - Country:US
Mailing Address - Phone:718-762-1700
Mailing Address - Fax:
Practice Address - Street 1:14205 ROOSEVELT AVE
Practice Address - Street 2:134
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6045
Practice Address - Country:US
Practice Address - Phone:718-762-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04796611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice