MEDICARE: TANATCHA KUKIRATIRAT

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	019033307	IL
2	1223G0001X	General Practice Dentistry	019.033307	IL

General Provider Information

NPI Number	:	1346913134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANATCHA KUKIRATIRAT

Provider Business Mailing Address
First Line	:	3425 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3433
Country	:	US
Telephone Number	:	773-256-9222
Fax Number	:

Provider Business Practice Location Address
First Line	:	3425 W PETERSON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60659-3433
Country	:	US
Telephone Number	:	773-256-9222
Fax Number	:

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

Provider Enumeration Date	:	07/27/2021
Last Update Date	:	07/27/2021

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Directions to “ TANATCHA KUKIRATIRAT ” Practice Location

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