Healthcare Provider Details

I. General information

NPI: 1588925010
Provider Name (Legal Business Name): ONE DENTAL SPECIALTIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 05/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S WESTERN AVE SUITE 116
LOS ANGELES CA
90005-3039
US

IV. Provider business mailing address

621 S WESTERN AVE SUITE 116
LOS ANGELES CA
90005-3039
US

V. Phone/Fax

Practice location:
  • Phone: 213-381-2828
  • Fax: 213-381-2882
Mailing address:
  • Phone: 213-381-2828
  • Fax: 213-381-2882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50451
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number51096
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number47496
License Number StateCA

VIII. Authorized Official

Name: JOON HO CHOE
Title or Position: DENTIST
Credential: D.D.S.
Phone: 213-381-2828