=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821291535
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIA-CHUN DAI D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2007
-----------------------------------------------------
Last Update Date | 11/21/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5240 HEMMINGTON BLVD
-----------------------------------------------------
City | SOLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44139-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-258-4497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5240 HEMMINGTON BLVD
-----------------------------------------------------
City | SOLON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44139-6902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-258-4497
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30.022523
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------