Provider Demographics
NPI:1679141139
Name:CHA, DONG YOUNG
Entity type:Individual
Prefix:
First Name:DONG YOUNG
Middle Name:
Last Name:CHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W 61ST ST APT 11E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-7611
Mailing Address - Country:US
Mailing Address - Phone:917-743-2223
Mailing Address - Fax:
Practice Address - Street 1:460 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2919
Practice Address - Country:US
Practice Address - Phone:201-608-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI027960001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice