Healthcare Provider Details

I. General information

NPI: 1619910767
Provider Name (Legal Business Name): PRASONG IAMSUREY D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 MAIN ST
KELSEYVILLE CA
95451-9402
US

IV. Provider business mailing address

4150 MAIN STREET PO BOX 514
KELSEYVILLE CA
95451-0514
US

V. Phone/Fax

Practice location:
  • Phone: 707-279-4251
  • Fax: 707-279-8335
Mailing address:
  • Phone: 707-279-4251
  • Fax: 707-279-8335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: