Healthcare Provider Details

I. General information

NPI: 1861365587
Provider Name (Legal Business Name): KANVARA VIROJSAKULCHAI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MARKET ST
REDDING CA
96001-1052
US

IV. Provider business mailing address

4211 BAYWOOD DR
REDDING CA
96003-2537
US

V. Phone/Fax

Practice location:
  • Phone: 530-337-5750
  • Fax:
Mailing address:
  • Phone: 323-698-6939
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDENT.DE.70022954
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberDDS113569
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License NumberDENT.DE.70022954
License Number StateWA
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS113569
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: