MEDICARE: Y CHAE DMD 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	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1760104129
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	Y CHAE DMD LLC

Provider Business Mailing Address
First Line	:	2206 SUSSEX WAY
Second Line	:
City	:	WOODSTOCK
State	:	MD
Zip	:	21163-1360
Country	:	US
Telephone Number	:	716-830-2502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1667 CROFTON CTR STE 7A
Second Line	:
City	:	CROFTON
State	:	MD
Zip	:	21114-1303
Country	:	US
Telephone Number	:	443-292-8009
Fax Number	:

Authorized Official
Title or Position	:	ENDODONTIST
Name	:	YOUNGSOOK CHAE
Credential	:
Telephone Number	:	716-830-2502

Provider Enumeration Date	:	09/13/2022
Last Update Date	:	09/13/2022

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