MEDICARE: DAVID JAEKWAN JO D.D.S., M.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30682	CA

General Provider Information

NPI Number	:	1689711822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JAEKWAN JO D.D.S., M.S.

Provider Business Mailing Address
First Line	:	21655 STONEHAVEN DR
Second Line	:
City	:	YORBA LINDA
State	:	CA
Zip	:	92887-2631
Country	:	US
Telephone Number	:	714-779-1650
Fax Number	:

Provider Business Practice Location Address
First Line	:	3120 S HACIENDA BLVD
Second Line	:	SUITE 205
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-6305
Country	:	US
Telephone Number	:	626-330-3116
Fax Number	:	626-333-5607

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

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/08/2007

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