MEDICARE: PRIYAWAT DENTAL GROUP INC

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

General Provider Information

NPI Number	:	1689513483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIYAWAT DENTAL GROUP INC

Provider Business Mailing 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	:	844-600-4099

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	:	844-600-4099

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	RUPPORN PRIYAWAT
Credential	:	DDS
Telephone Number	:	951-999-1239

Provider Enumeration Date	:	03/26/2026
Last Update Date	:	03/26/2026

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