Healthcare Provider Details

I. General information

NPI: 1659624153
Provider Name (Legal Business Name): KYUNG-SOO CHOI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2012
Last Update Date: 08/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 N LAKE SHORE DR #215
CHICAGO IL
60611-3427
US

IV. Provider business mailing address

505 N LAKE SHORE DR #215
CHICAGO IL
60611-3427
US

V. Phone/Fax

Practice location:
  • Phone: 213-245-4564
  • Fax:
Mailing address:
  • Phone: 213-245-4564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number021002754
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019024334
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: