1720608482 NPI number — DR. JESSICA MARIE CORNELIUS CHENG DDS

Table of content: DR. JESSICA MARIE CORNELIUS CHENG DDS (NPI 1720608482)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720608482 NPI number — DR. JESSICA MARIE CORNELIUS CHENG DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHENG
Provider First Name:
JESSICA
Provider Middle Name:
MARIE CORNELIUS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CORNELIUS
Provider Other First Name:
JESSICA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720608482
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PSC 41 BOX 5154
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
APO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09464-0052
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
48TH MDG
Provider Second Line Business Practice Location Address:
UNIT 5115
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09461-5115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-226-8883
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0000011417 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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