Healthcare Provider Details

I. General information

NPI: 1972603421
Provider Name (Legal Business Name): PICHAK KELK DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TOWN & COUNTRY RD. SUITE 46
ORANGE CA
92868
US

IV. Provider business mailing address

1111 TOWN & COUNTRY RD. SUITE 46
ORANGE CA
92868
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-4441
  • Fax: 714-835-0188
Mailing address:
  • Phone: 714-835-4441
  • Fax: 714-835-0188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number43450
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: