Healthcare Provider Details

I. General information

NPI: 1407558109
Provider Name (Legal Business Name): RENNY CHO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S TOWNLINE RD
WAUTOMA WI
54982-6922
US

IV. Provider business mailing address

51 MCARTHUR AVE
STATEN ISLAND NY
10312-1924
US

V. Phone/Fax

Practice location:
  • Phone: 180-833-3360
  • Fax:
Mailing address:
  • Phone: 917-836-1730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6001632
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: