=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134512932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LRD DANBURY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2015
-----------------------------------------------------
Last Update Date | 07/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2 GLEN HILL RD
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811-4906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-797-9392
-----------------------------------------------------
Fax | 203-797-9588
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 GLEN HILL RD
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06811-4906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-797-9392
-----------------------------------------------------
Fax | 203-797-9588
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JUSTINA CHO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-369-6918
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 10227
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 10227
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------