MEDICARE: RUPPORN PRIYAWAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	61647	CA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	61647	CA

General Provider Information

NPI Number	:	1033453667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUPPORN PRIYAWAT

Provider Business Mailing Address
First Line	:	264 DESERT BLOOM
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92618-8872
Country	:	US
Telephone Number	:	951-999-1239
Fax Number	:

Provider Business Practice Location Address
First Line	:	15911 POMONA RINCON RD STE 120
Second Line	:
City	:	CHINO HILLS
State	:	CA
Zip	:	91709-5567
Country	:	US
Telephone Number	:	909-497-9449
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2012
Last Update Date	:	07/31/2023

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Directions to “ RUPPORN PRIYAWAT ” Practice Location

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