MEDICARE: DR. JAEWOONG CHOI D.D.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	122300000X	Dentist	32516	TX

General Provider Information

NPI Number	:	1871045393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAEWOONG CHOI D.D.S.

Provider Business Mailing Address
First Line	:	432 SAMUELS AVE APT 2305
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2483
Country	:	US
Telephone Number	:	574-309-2579
Fax Number	:

Provider Business Practice Location Address
First Line	:	432 SAMUELS AVE APT 2305
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-2483
Country	:	US
Telephone Number	:	574-309-2579
Fax Number	:

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

Provider Enumeration Date	:	11/01/2016
Last Update Date	:	11/01/2016

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