Healthcare Provider Details

I. General information

NPI: 1992285357
Provider Name (Legal Business Name): JERICHO ORTHODONTICS AND PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 N BROADWAY
JERICHO NY
11753-2015
US

IV. Provider business mailing address

14 SHERWOOD LN
ROSLYN HEIGHTS NY
11577-2511
US

V. Phone/Fax

Practice location:
  • Phone: 917-657-3934
  • Fax:
Mailing address:
  • Phone: 917-657-3934
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number054937
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9574651
License Number StateNY

VIII. Authorized Official

Name: DAVID CHOI
Title or Position: PRESIDENT
Credential: DDS
Phone: 917-657-3934