Provider Demographics
NPI:1063671022
Name:CHOI, MAL BONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:MAL BONG
Middle Name:
Last Name:CHOI
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 1:3530 HENRY HUDSON PKWY
Mailing Address - Street 2:APT 1F
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1306
Mailing Address - Country:US
Mailing Address - Phone:646-763-1145
Mailing Address - Fax:718-601-3964
Practice Address - Street 1:605 BROAD AVE
Practice Address - Street 2:SUIT # 203
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1697
Practice Address - Country:US
Practice Address - Phone:201-943-9424
Practice Address - Fax:201-943-9485
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI019123001223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics