Healthcare Provider Details

I. General information

NPI: 1275223505
Provider Name (Legal Business Name): MISS APISSADA JINDAROJANAKUL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2023
Last Update Date: 09/14/2023
Certification Date: 09/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HARVARD DENTAL CENTER 188 LONGWOOD AVE.
BOSTON ME
02115
US

IV. Provider business mailing address

HARVARD DENTAL CENTER 188 LONGWOOD AVE.
BOSTON ME
02115
US

V. Phone/Fax

Practice location:
  • Phone: 617-432-1434
  • Fax:
Mailing address:
  • Phone: 617-432-1434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL15760
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: