Provider Demographics
NPI:1043820442
Name:CHOU, KATIE JIA
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JIA
Last Name:CHOU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31516 SEA SHADOWS WAY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-5409
Mailing Address - Country:US
Mailing Address - Phone:949-463-7586
Mailing Address - Fax:
Practice Address - Street 1:3003 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-4301
Practice Address - Country:US
Practice Address - Phone:608-244-8050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI10024281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program