Basic Information
| Provider Information | |||||||||
| NPI: | 1497846752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NG | ||||||||
| FirstName: | CHEUKHUNG | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 E 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783324822 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3613960370 | ||||||||
| FaxNumber: | 3616642248 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 FLOURNOY RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | ALICE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3616641417 | ||||||||
| FaxNumber: | 1855350561 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 03/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 15197 | TX | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 009033401 | 05 | TX | MEDICAID | 133270208 | 05 | TX | MEDICAID | D15197 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |