Provider Demographics
NPI:1427403765
Name:CHENG, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:CHENG
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 1:340 KELLEY PKWY
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3811
Mailing Address - Country:US
Mailing Address - Phone:573-582-1234
Mailing Address - Fax:
Practice Address - Street 1:1225 AGUILAR DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361-2723
Practice Address - Country:US
Practice Address - Phone:573-582-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-24
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE608035951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice