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General NPI Number Information
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NPI Number | 1780902734
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Entity Type | Individual
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Provider Name | JOMPOBE VUTHIGANON DMD
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Gender | Male
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Dates
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Enumeration Date | 05/13/2010
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Last Update Date | 05/13/2010
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Provider Practice Location Address
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Address Line | 173 ASHLEY AVE BSB RM 546
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City | CHARLESTON
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State | SC
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Zip | 29425-8908
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Country | US
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Telephone | 843-792-2341
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1266
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City | RIDGELAND
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State | SC
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Zip | 29936-2621
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Country | US
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Telephone | 843-870-8555
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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 | 4600
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License Number State | SC
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