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	DN17989	FL

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	:	1144576737
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	:	407-641-8932

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	:	407-641-8932

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SIRIN THANASASAVAT
Credential	:	D.M.D
Telephone Number	:	407-929-7095

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	08/01/2012

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