Healthcare Provider Details

I. General information

NPI: 1558199257
Provider Name (Legal Business Name): PONGSAKORN POOVARODOM DDS, MSC, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 ASHLEY AVE # MSC507
CHARLESTON SC
29425-8908
US

IV. Provider business mailing address

3489 BILLINGS ST
MOUNT PLEASANT SC
29466-6882
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-3811
  • Fax:
Mailing address:
  • Phone: 854-858-2195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number60
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: