Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 56408 | CA |
NPI | 1003003781 |
---|---|
Provider Name | Dr. Supak Choti |
First Address | Redding, CA 96001-0616 |
Second Address | Burney, CA 96013-9792 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/09/2007 |
Last Update Date | 04/12/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
56408 | (05) | CA |