MEDICARE: DR. PRANEE V POOUDOMSAK

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	122300000X	Dentist	38764	CA

General Provider Information

NPI Number	:	1750687984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PRANEE V POOUDOMSAK

Provider Business Mailing Address
First Line	:	1850 S WATERMAN AVE STE B
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-2852
Country	:	US
Telephone Number	:	909-890-1529
Fax Number	:	909-890-1739

Provider Business Practice Location Address
First Line	:	1850 S WATERMAN AVE STE B
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-2852
Country	:	US
Telephone Number	:	909-890-1529
Fax Number	:	909-890-1739

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

Provider Enumeration Date	:	02/05/2011
Last Update Date	:	02/05/2011

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