MEDICARE: DR. JACKIE CHI DMD, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	55253	CA

General Provider Information

NPI Number	:	1144408725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACKIE CHI DMD, MS

Provider Business Mailing Address
First Line	:	2707 E VALLEY BLVD
Second Line	:	STE. 107
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3195
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2707 E VALLEY BLVD
Second Line	:	STE. 107
City	:	WEST COVINA
State	:	CA
Zip	:	91792-3195
Country	:	US
Telephone Number	:	626-581-1929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2008
Last Update Date	:	02/05/2015

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