Provider Demographics
NPI:1417791682
Name:CHO, TAEWON TAD (DMD)
Entity type:Individual
Prefix:
First Name:TAEWON
Middle Name:TAD
Last Name:CHO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 APEX LOOP APT 202
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-6951
Mailing Address - Country:US
Mailing Address - Phone:678-300-9720
Mailing Address - Fax:
Practice Address - Street 1:2465 IRON POINT RD STE 120
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-8754
Practice Address - Country:US
Practice Address - Phone:678-300-9720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-22
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS110270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty