Healthcare Provider Details

I. General information

NPI: 1376987636
Provider Name (Legal Business Name): UTUMPORN LAOWANSIRI D.D.S, M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PENNY LAOWANSIRI D.D.S, M.S.

II. Dates (important events)

Enumeration Date: 04/17/2013
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 DANIELS RD STE 104
WINTER GARDEN FL
34787-7000
US

IV. Provider business mailing address

4150 EASTGATE DR APT 8203
ORLANDO FL
32839-5238
US

V. Phone/Fax

Practice location:
  • Phone: 407-656-0990
  • Fax:
Mailing address:
  • Phone: 314-541-9377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 20017
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: