Provider Demographics
NPI:1841784493
Name:CHEN, JEFFREY JAY (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JAY
Last Name:CHEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 WORDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4766
Mailing Address - Country:US
Mailing Address - Phone:309-363-0260
Mailing Address - Fax:
Practice Address - Street 1:9016 N ALLEN RD STE B
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1560
Practice Address - Country:US
Practice Address - Phone:309-363-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018022438122300000X
IL019.031703122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist