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General NPI Number Information
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NPI Number | 1164652053
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Entity Type | Individual
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Provider Name | CHANCHAI SANGSURASAK D.D.S
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Gender | Male
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Dates
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Enumeration Date | 07/25/2009
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Last Update Date | 10/02/2013
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Provider Practice Location Address
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Address Line | 3410 LA SIERRA AVE STE D
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City | RIVERSIDE
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State | CA
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Zip | 92503-5205
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Country | US
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Telephone | 951-354-9550
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Fax |
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Provider Business Mailing Address
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Address Line | 3410 LA SIERRA AVE STE D
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City | RIVERSIDE
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State | CA
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Zip | 92503-5205
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Country | US
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Telephone | 951-354-9550
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 58501
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License Number State | CA
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