MEDICARE: SIRIN THANASASAVAT, DMD PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry		FL
2	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104311331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIRIN THANASASAVAT, DMD PA

Provider Business Mailing Address
First Line	:	8010 SUNPORT DR STE 115
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7897
Country	:	US
Telephone Number	:	407-412-7887
Fax Number	:	407-930-2758

Provider Business Practice Location Address
First Line	:	8010 SUNPORT DR STE 115
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-7897
Country	:	US
Telephone Number	:	407-412-7887
Fax Number	:	407-930-2758

Authorized Official
Title or Position	:	MANAGER
Name	:	THIDA THANA
Credential	:
Telephone Number	:	407-542-8383

Provider Enumeration Date	:	06/29/2018
Last Update Date	:	04/19/2024

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