Basic Information
| Provider Information | |||||||||
| NPI: | 1003003781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOTI | ||||||||
| FirstName: | SUPAK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3671 FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | REDDING | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960010616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305103077 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 38096 HIGHWAY 299 E | ||||||||
| Address2: | |||||||||
| City: | BURNEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960139792 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5304105851 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2007 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 56408 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 56408 | 05 | CA | MEDICAID |