Provider Demographics
NPI:1033453667
Name:PRIYAWAT, RUPPORN
Entity Type:Individual
Prefix:
First Name:RUPPORN
Middle Name:
Last Name:PRIYAWAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 DESERT BLOOM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-8872
Mailing Address - Country:US
Mailing Address - Phone:951-999-1239
Mailing Address - Fax:
Practice Address - Street 1:15911 POMONA RINCON RD STE 120
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5567
Practice Address - Country:US
Practice Address - Phone:909-497-9449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-20
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61647122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist