Provider Demographics
NPI:1003824517
Name:CHOI, CHARLES JAE (DDS)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JAE
Last Name:CHOI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 CENTER POINT RD NE STE 3
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-5566
Mailing Address - Country:US
Mailing Address - Phone:319-393-4828
Mailing Address - Fax:319-393-5816
Practice Address - Street 1:3500 CENTER POINT RD NE
Practice Address - Street 2:SUITE3
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-5566
Practice Address - Country:US
Practice Address - Phone:319-393-4828
Practice Address - Fax:319-393-5816
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA66421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0035022Medicaid