Provider Demographics
NPI:1063290575
Name:ZHAO, CHENGLONG (DDS)
Entity type:Individual
Prefix:
First Name:CHENGLONG
Middle Name:
Last Name:ZHAO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7679 ROTUNDA CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0111
Mailing Address - Country:US
Mailing Address - Phone:909-264-0308
Mailing Address - Fax:
Practice Address - Street 1:3485 MADISON ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92504-3716
Practice Address - Country:US
Practice Address - Phone:909-264-0308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1093261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice