Provider Demographics
NPI:1740665058
Name:CHO, JAEMI (DDS)
Entity type:Individual
Prefix:
First Name:JAEMI
Middle Name:
Last Name:CHO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:JAE
Other - Middle Name:MI
Other - Last Name:CHO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:10844 ANVIK CIR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8279
Mailing Address - Country:US
Mailing Address - Phone:509-842-6019
Mailing Address - Fax:
Practice Address - Street 1:1136 N MULDOON RD STE 110
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504
Practice Address - Country:US
Practice Address - Phone:907-333-6666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-28
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX312891223G0001X
AK1328661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1740665058Medicaid