Provider Demographics
NPI:1245300763
Name:CHUO, FREDERCIK CHIABING
Entity type:Individual
Prefix:
First Name:FREDERCIK
Middle Name:CHIABING
Last Name:CHUO
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 1:217 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541-2503
Mailing Address - Country:US
Mailing Address - Phone:850-837-7448
Mailing Address - Fax:850-837-2042
Practice Address - Street 1:401 S MAIN ST
Practice Address - Street 2:STE B5
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30004-1974
Practice Address - Country:US
Practice Address - Phone:770-663-8717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0131101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA143808112AMedicaid