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General NPI Number Information
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NPI Number | 1386795961
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Entity Type | Individual
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Provider Name | ALI POOTRAKUL D.D.S
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Gender | Male
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 11/18/2019
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Provider Practice Location Address
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Address Line | 16002 HAWTHORNE BLVD
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City | LAWNDALE
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State | CA
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Zip | 90260-2646
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Country | US
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Telephone | 310-371-4104
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Fax |
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Provider Business Mailing Address
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Address Line | 8811 169TH ST ORAL SURGEON SUITE 1ST FL.
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City | JAMAICA
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State | NY
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Zip | 11432-4430
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Country | US
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Telephone | 718-658-1200
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Fax | 718-658-1484
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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 | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 052450
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 60258
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License Number State | CA
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