=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205109188
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHOI PERIODONTICS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2012
-----------------------------------------------------
Last Update Date | 02/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 505 N LAKE SHORE DR #215
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-467-3201
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 N LAKE SHORE DR #215
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60611-3427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-961-3179
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. YOUNG CHOI
-----------------------------------------------------
Credential | D.M.D., M.S.
-----------------------------------------------------
Telephone | 312-467-3201
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 019025040
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 021002061
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------