Provider Demographics
NPI:1629484324
Name:CHOI, BRIAN (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:CHOI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 VISA DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1604 VISA DR
Practice Address - Street 2:UNIT #3
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2195
Practice Address - Country:US
Practice Address - Phone:309-660-9159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190297891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice