1730266974 NPI number — DR. P.PENNY SIRIWAT D.D.S., M.S.

Table of content: (NPI 1154660348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730266974 NPI number — DR. P.PENNY SIRIWAT D.D.S., M.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIRIWAT
Provider First Name:
P.PENNY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S., M.S.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1730266974
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 S BEACH BLVD
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
ANAHEIM
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92804-1812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-527-9006
Provider Business Mailing Address Fax Number:
714-527-5681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 S BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
ANAHEIM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92804-1812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-527-9006
Provider Business Practice Location Address Fax Number:
714-527-5681
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  32994 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: B32994-01 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CGP#169380 . This is a "CALIFORNIA CHILDREN SERVI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 32994 . This is a "DENTAL LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: B32994-02 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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