Provider Demographics
NPI:1083142269
Name:CHOI, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:CHOI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13346 CHASE ST
Mailing Address - Street 2:
Mailing Address - City:ARLETA
Mailing Address - State:CA
Mailing Address - Zip Code:91331
Mailing Address - Country:US
Mailing Address - Phone:818-671-7268
Mailing Address - Fax:
Practice Address - Street 1:1295 S LA BREA AVE STE 101
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-0972
Practice Address - Country:US
Practice Address - Phone:310-672-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1025421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANAMedicaid