1144312851 NPI number — S AND S DENTAL

Table of content: DR. PUMIPAK TANTAMJARIK MD, FAAFP (NPI 1891789566)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144312851 NPI number — S AND S DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S AND S DENTAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144312851
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2121 E OLTORF ST
Provider Second Line Business Mailing Address:
SUITE #103
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78741-4500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-326-3003
Provider Business Mailing Address Fax Number:
512-326-5304

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2121 E OLTORF ST
Provider Second Line Business Practice Location Address:
SUITE #103
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78741-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-326-3003
Provider Business Practice Location Address Fax Number:
512-326-5304
Provider Enumeration Date:
09/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ISTRE
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
SHAYNE
Authorized Official Title or Position:
DIRECT OWNER
Authorized Official Telephone Number:
512-426-2619

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: G60901-1 . This is a "TEXAS CHIP PROVIDER NUMBE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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