=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386363760
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CKV PEDIATRIC DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2022
-----------------------------------------------------
Last Update Date | 08/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1618 FM 423 STE 100
-----------------------------------------------------
City | FRISCO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75033-0040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-331-6541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 127 ROLLING FORK BND
-----------------------------------------------------
City | IRVING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75039-3805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-331-6541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. YI-JU CHEN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 617-331-6541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------