=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760864797
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. CHI MBA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2015
-----------------------------------------------------
Last Update Date | 06/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8620 SKILLMAN ST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75243-8216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-341-0900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 610 PINE VLY
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75081-5138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-213-2658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 30951
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------