Provider Demographics
NPI:1003222811
Name:JO, CHUNGMI (DDS)
Entity Type:Individual
Prefix:
First Name:CHUNGMI
Middle Name:
Last Name:JO
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 1:3905 JULIAN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76244-7650
Mailing Address - Country:US
Mailing Address - Phone:713-471-0122
Mailing Address - Fax:
Practice Address - Street 1:1618 W 287 BUSINESS
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-4706
Practice Address - Country:US
Practice Address - Phone:972-937-6654
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX299691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice