Healthcare Provider Details

I. General information

NPI: 1083358345
Provider Name (Legal Business Name): JAE YEON CHOI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 DELAWARE ST SE
MINNEAPOLIS MN
55455-0357
US

IV. Provider business mailing address

104 N PLUM GROVE RD APT 400
PALATINE IL
60067-5279
US

V. Phone/Fax

Practice location:
  • Phone: 612-625-2495
  • Fax:
Mailing address:
  • Phone: 929-528-2194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.034481
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR917
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: