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General NPI Number Information
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NPI Number | 1265624399
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Entity Type | Organization
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Legal Business Name | JIRAWAN SRIVIVATANAKUL D.D.S., INC.
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Dates
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Enumeration Date | 08/13/2007
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Last Update Date | 08/13/2007
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Provider Practice Location Address
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Address Line | 17360 NORWALK BLVD
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City | CERRITOS
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State | CA
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Zip | 90703-2748
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Country | US
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Telephone | 562-402-8899
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Fax |
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Provider Business Mailing Address
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Address Line | 17360 NORWALK BLVD
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City | CERRITOS
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State | CA
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Zip | 90703-2748
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Country | US
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Telephone | 562-402-8899
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JIRAWAN SRIVIVATANAKUL
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Credential | D.D.S.
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Telephone | 562-402-8899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 48771
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License Number State | CA
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