Healthcare Provider Details

I. General information

NPI: 1497311260
Provider Name (Legal Business Name): JACQUELYN CHOU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2019
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MOUNT AUBURN ST
CAMBRIDGE MA
02138-5775
US

IV. Provider business mailing address

802 CONSTITUTION AVE
LITTLETON MA
01460-1137
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberDN1858309
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: