Healthcare Provider Details

I. General information

NPI: 1861955726
Provider Name (Legal Business Name): JORDAN SOLOMON CHU DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2019
Last Update Date: 08/10/2026
Certification Date: 08/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 5024
APO AP
96319-5024
US

IV. Provider business mailing address

UNIT 5024
APO AP
96319-5024
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-6700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number114255239921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number35660
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: