1558199257 NPI number — DR. PONGSAKORN POOVARODOM DDS, MSC, PHD

Table of content: MR. ANTONIO S MOLINA MCBRIDE FAMILY NP (NPI 1548884208)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558199257 NPI number — DR. PONGSAKORN POOVARODOM DDS, MSC, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POOVARODOM
Provider First Name:
PONGSAKORN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MSC, PHD
Provider Gender Code:
M

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:
1558199257
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3489 BILLINGS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT PLEASANT
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29466-6882
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
854-858-2195
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
173 ASHLEY AVE # MSC507
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29425-8908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-792-3811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2024

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: 1223P0700X , with the licence number:  60 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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