MEDICARE: SUMALEE SANGSURASAK DDS

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	1223P0221X	Pediatric Dentistry	41992	CA

General Provider Information

NPI Number	:	1235314923
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUMALEE SANGSURASAK DDS

Provider Business Mailing Address
First Line	:	1121 E GREEN ST
Second Line	:	SUITE A
City	:	PASADENA
State	:	CA
Zip	:	91106-2505
Country	:	US
Telephone Number	:	626-792-2782
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 E GREEN ST
Second Line	:	SUITE A
City	:	PASADENA
State	:	CA
Zip	:	91106-2505
Country	:	US
Telephone Number	:	626-792-2782
Fax Number	:

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

Provider Enumeration Date	:	01/01/2008
Last Update Date	:	01/01/2008

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