MEDICARE: DR. KONGKIAT RATANATHARATHORN D.D.S.

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	55922	CA
2	122300000X	Dentist	DE60748920	WA

General Provider Information

NPI Number	:	1598965824
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KONGKIAT RATANATHARATHORN D.D.S.

Provider Business Mailing Address
First Line	:	824 32ND AVE S
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98144-3241
Country	:	US
Telephone Number	:	99-586-2220
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 BRIDGEPORT WAY W
Second Line	:
City	:	UNIVERSITY PLACE
State	:	WA
Zip	:	98466-4416
Country	:	US
Telephone Number	:	253-212-3430
Fax Number	:

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

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	01/02/2023

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