Healthcare Provider Details

I. General information

NPI: 1770635278
Provider Name (Legal Business Name): KANOKRAJ SRISUKHO D.D.S., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE DENTAL FACULTY PRACTICE ASSOCIATION INC.
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

5463 COACHMAN RD APT. N
COLUMBUS OH
43220-6276
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-1472
  • Fax:
Mailing address:
  • Phone: 614-292-7054
  • Fax: 614-292-9422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number71-000165
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: