MEDICARE: TEERARAT NEAL PHUATRAKOON

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	1223P0300X	Periodontics	DDS107567	CA

General Provider Information

NPI Number	:	1194619155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEERARAT NEAL PHUATRAKOON

Provider Business Mailing Address
First Line	:	PO BOX 1266
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91729-1266
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1623 SANTA CLARA DR STE 100
Second Line	:
City	:	ROSEVILLE
State	:	CA
Zip	:	95661-3589
Country	:	US
Telephone Number	:	916-788-1114
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2025
Last Update Date	:	11/24/2025

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