Provider Demographics
NPI:1144408725
Name:CHI, JACKIE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:
Last Name:CHI
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2707 E VALLEY BLVD
Mailing Address - Street 2:STE. 107
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-3195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2707 E VALLEY BLVD
Practice Address - Street 2:STE. 107
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-3195
Practice Address - Country:US
Practice Address - Phone:626-581-1929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA552531223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics