Provider Demographics
NPI:1790180693
Name:QUEENS ORAL AND FACIAL SURGERY
Entity Type:Organization
Organization Name:QUEENS ORAL AND FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEHYUN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHONG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-358-5488
Mailing Address - Street 1:40-19 159TH ST.
Mailing Address - Street 2:1 FL.
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358
Mailing Address - Country:US
Mailing Address - Phone:718-358-5488
Mailing Address - Fax:917-285-2676
Practice Address - Street 1:40-19 159TH ST.
Practice Address - Street 2:1 FL.
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11358
Practice Address - Country:US
Practice Address - Phone:718-358-5488
Practice Address - Fax:917-285-2676
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:QUEENS ORAL AND FACIAL SURGERY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051051122300000X
NY051035122300000X
NY0518291223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty