MEDICARE: JIORTHODONTICS LLC

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	0401410425	VA

General Provider Information

NPI Number	:	1750729596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JIORTHODONTICS LLC

Provider Business Mailing Address
First Line	:	798 SOUTHPARK BLVD STE 12
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3600
Country	:	US
Telephone Number	:	804-520-6050
Fax Number	:

Provider Business Practice Location Address
First Line	:	798 SOUTHPARK BLVD STE 12
Second Line	:
City	:	COLONIAL HEIGHTS
State	:	VA
Zip	:	23834-3600
Country	:	US
Telephone Number	:	804-520-6050
Fax Number	:

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. JOHN C. JI
Credential	:	D.M.D.
Telephone Number	:	804-520-6050

Provider Enumeration Date	:	06/13/2013
Last Update Date	:	06/13/2013

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