Provider Demographics
NPI:1649306168
Name:JENG, CHARLES C (DDS)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:C
Last Name:JENG
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 1:2748 AQUA VERDE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077
Mailing Address - Country:US
Mailing Address - Phone:310-476-3568
Mailing Address - Fax:310-472-4116
Practice Address - Street 1:3011 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-829-1559
Practice Address - Fax:310-828-7383
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23887122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist