Provider Demographics
NPI:1164902664
Name:CHEN, JEFFERY (DMD)
Entity type:Individual
Prefix:
First Name:JEFFERY
Middle Name:
Last Name:CHEN
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 1:11334 SSG SIMS BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79908
Mailing Address - Country:US
Mailing Address - Phone:915-742-0086
Mailing Address - Fax:
Practice Address - Street 1:228 HAMILTON CROSSING DR
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701-2262
Practice Address - Country:US
Practice Address - Phone:865-463-5977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-15
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041728122300000X, 204E00000X
TN12406204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist