MEDICARE: SUPAKIT

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	21159	TX

General Provider Information

NPI Number	:	1376652248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUPAKIT

Provider Business Mailing Address
First Line	:	PO BOX 35408
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-0408
Country	:	US
Telephone Number	:	214-456-8825
Fax Number	:	214-456-8256

Provider Business Practice Location Address
First Line	:	6300 HARRY HINES BLVD
Second Line	:	SUITE 600
City	:	DALLAS
State	:	TX
Zip	:	75235-5259
Country	:	US
Telephone Number	:	214-456-8825
Fax Number	:	214-456-8256

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUPAKIT PEANCHITLERTKAJORN
Credential	:	DDS, MDS
Telephone Number	:	214-456-8825

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2020

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Directions to “SUPAKIT ” Practice Location

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