Provider Demographics
NPI:1932268018
Name:TSE, JACK JEUN CHEUNG (DMD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:JEUN CHEUNG
Last Name:TSE
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 1:430 ROBINSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550
Mailing Address - Country:US
Mailing Address - Phone:845-561-7255
Mailing Address - Fax:845-561-5522
Practice Address - Street 1:430 ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550
Practice Address - Country:US
Practice Address - Phone:845-561-7255
Practice Address - Fax:845-561-5522
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2013-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0401091223S0112X
CT108691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00993288Medicaid
CT008043473Medicaid
CT008043473Medicaid
NY00993288Medicaid