Healthcare Provider Details

I. General information

NPI: 1366591265
Provider Name (Legal Business Name): PAIROT TAYAPONGSAK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 NORMANDY BLVD
JACKSONVILLE FL
32205-6211
US

IV. Provider business mailing address

7101 NORMANDY BLVD
JACKSONVILLE FL
32205-6211
US

V. Phone/Fax

Practice location:
  • Phone: 904-786-9200
  • Fax: 904-786-1116
Mailing address:
  • Phone: 904-786-9200
  • Fax: 904-786-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN12215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: