Provider Demographics
NPI:1700186731
Name:CHAE, YOUNGSOOK
Entity Type:Individual
Prefix:
First Name:YOUNGSOOK
Middle Name:
Last Name:CHAE
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 1:2825 N STATE HIGHWAY 360
Mailing Address - Street 2:APT 837
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75050-7842
Mailing Address - Country:US
Mailing Address - Phone:716-830-2502
Mailing Address - Fax:
Practice Address - Street 1:529 N VALLEY MILLS DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5234
Practice Address - Country:US
Practice Address - Phone:254-230-1578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist