=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528246618
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GLENDALE DENTAL ASSOCIATES II, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2008
-----------------------------------------------------
Last Update Date | 12/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6202 EVANSTON AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-251-0085
-----------------------------------------------------
Fax | 317-259-9084
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6202 EVANSTON AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46220-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-251-0085
-----------------------------------------------------
Fax | 317-259-9084
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. JOHN CHO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 317-251-0085
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12010539A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------