Provider Demographics
NPI:1003003781
Name:CHOTI, SUPAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUPAK
Middle Name:
Last Name:CHOTI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3671 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96001-0616
Mailing Address - Country:US
Mailing Address - Phone:530-510-3077
Mailing Address - Fax:
Practice Address - Street 1:38096 HIGHWAY 299 E
Practice Address - Street 2:
Practice Address - City:BURNEY
Practice Address - State:CA
Practice Address - Zip Code:96013-9792
Practice Address - Country:US
Practice Address - Phone:530-410-5851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56408Medicaid