Healthcare Provider Details

I. General information

NPI: 1346913134
Provider Name (Legal Business Name): TANATCHA KUKIRATIRAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 07/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 W PETERSON AVE
CHICAGO IL
60659-3433
US

IV. Provider business mailing address

3425 W PETERSON AVE
CHICAGO IL
60659-3433
US

V. Phone/Fax

Practice location:
  • Phone: 773-256-9222
  • Fax:
Mailing address:
  • Phone: 773-256-9222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019033307
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.033307
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: