MEDICARE: JESSICA CHOI, DMD, DENTAL CORPORATION

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1205440211
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JESSICA CHOI, DMD, DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	2318 HUNTINGTON DR
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2641
Country	:	US
Telephone Number	:	626-360-4500
Fax Number	:

Provider Business Practice Location Address
First Line	:	2318 HUNTINGTON DR
Second Line	:
City	:	SAN MARINO
State	:	CA
Zip	:	91108-2641
Country	:	US
Telephone Number	:	626-360-4500
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JESSICA CHOI
Credential	:	DMD
Telephone Number	:	626-360-4500

Provider Enumeration Date	:	09/08/2020
Last Update Date	:	09/08/2020

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