=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952673196
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JULIET TAN CHUA, D.M.D., INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2012
-----------------------------------------------------
Last Update Date | 02/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 S STATE COLLEGE BLVD
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92806-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-399-3668
-----------------------------------------------------
Fax | 714-399-9310
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 S STATE COLLEGE BLVD
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92806-4527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-399-3668
-----------------------------------------------------
Fax | 714-399-9310
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JULIET TAN CHUA
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 714-399-3668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 33674
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------