Provider Demographics
NPI:1710265921
Name:CHENG, JERRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:CHENG
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 1:11401 NORRIS DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20902-2514
Mailing Address - Country:US
Mailing Address - Phone:217-721-4867
Mailing Address - Fax:
Practice Address - Street 1:2040 COLISEUM DR
Practice Address - Street 2:SUITE A27
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-3200
Practice Address - Country:US
Practice Address - Phone:757-262-0020
Practice Address - Fax:757-224-3398
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2012-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401413238122300000X
IL019.028704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist