MEDICARE: DR. KIATKACHORN RATANATHARATHORN DDS

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	102782	CA

General Provider Information

NPI Number	:	1750867487
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIATKACHORN RATANATHARATHORN DDS

Provider Business Mailing Address
First Line	:	2420 S AZUSA AVE
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1512
Country	:	US
Telephone Number	:	626-810-2691
Fax Number	:

Provider Business Practice Location Address
First Line	:	2420 S AZUSA AVE
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1512
Country	:	US
Telephone Number	:	626-810-2691
Fax Number	:

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

Provider Enumeration Date	:	07/16/2018
Last Update Date	:	02/28/2023

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