=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164592259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SURAT ATTAPHITAYA DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2006
-----------------------------------------------------
Last Update Date | 05/21/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 E PROSPECT AVE STE 800
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-765-2000
-----------------------------------------------------
Fax | 580-765-2001
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 E PROSPECT AVE STE 800
-----------------------------------------------------
City | PONCA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74601-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-765-2000
-----------------------------------------------------
Fax | 580-765-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 54986
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 184
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 22054
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------