Basic Information
Provider Information
NPI: 1003003781
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHOTI
FirstName: SUPAK
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X56408CAY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
5640805CA MEDICAID


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