=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417410382
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY SU CHUNG CHOI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2019
-----------------------------------------------------
Last Update Date | 01/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1642 KINGS HWY N
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08034-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-433-6045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 116 CHERRY TREE CT
-----------------------------------------------------
City | MOUNT LAUREL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08054-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-332-0148
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0700X
-----------------------------------------------------
Taxonomy Name | Prosthodontics
-----------------------------------------------------
License Number | 22DI02976700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------