MEDICARE: YUTDHASAK KJORNRATTANAWANICH DMD

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	9427	CT

General Provider Information

NPI Number	:	1982766689
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YUTDHASAK KJORNRATTANAWANICH DMD

Provider Business Mailing Address
First Line	:	PO BOX 3189
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13220-3189
Country	:	US
Telephone Number	:	315-454-6000
Fax Number	:	315-454-8650

Provider Business Practice Location Address
First Line	:	1128 FARMINGTON AVE
Second Line	:
City	:	BRISTOL
State	:	CT
Zip	:	06010-4752
Country	:	US
Telephone Number	:	860-585-1716
Fax Number	:	860-585-1758

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

Provider Enumeration Date	:	12/16/2006
Last Update Date	:	07/08/2007

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