=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851062913
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOO DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2021
-----------------------------------------------------
Last Update Date | 12/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9975 W LINCOLN HWY
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-2049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-298-0819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9975 W LINCOLN HWY STE 1
-----------------------------------------------------
City | FRANKFORT
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60423-2048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-469-3900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. REGINALD WOO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 815-469-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------