Provider Demographics
NPI:1982261004
Name:CHAE, EARNEST
Entity type:Individual
Prefix:
First Name:EARNEST
Middle Name:
Last Name:CHAE
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 1:19016 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-7103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11395 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-2485
Practice Address - Country:US
Practice Address - Phone:310-639-0884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111091122300000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes122300000XDental ProvidersDentist