MEDICARE: DR. THANH HAI CHU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	58465	CA

General Provider Information

NPI Number	:	1477787943
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THANH HAI CHU DDS

Provider Business Mailing Address
First Line	:	4403 MARLBOROUGH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4727
Country	:	US
Telephone Number	:	619-282-7011
Fax Number	:	619-282-1440

Provider Business Practice Location Address
First Line	:	4403 MARLBOROUGH AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-4727
Country	:	US
Telephone Number	:	619-282-7011
Fax Number	:	619-282-1440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	12/09/2009

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