MEDICARE: DR. KANOKNUCH SHIFLETT D.D.S.

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	1223P0221X	Pediatric Dentistry	40303	CA

General Provider Information

NPI Number	:	1609873876
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KANOKNUCH SHIFLETT D.D.S.

Provider Business Mailing Address
First Line	:	906 S SUNSET AVE STE 105
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91790-3400
Country	:	US
Telephone Number	:	626-480-1543
Fax Number	:	626-480-0622

Provider Business Practice Location Address
First Line	:	906 S SUNSET AVE STE 105
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91790-3400
Country	:	US
Telephone Number	:	626-480-1543
Fax Number	:	626-480-0622

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

Provider Enumeration Date	:	07/03/2005
Last Update Date	:	07/21/2022

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