Provider Demographics
NPI:1124223540
Name:CHAROENKUL, WISANU (DDS)
Entity Type:Individual
Prefix:DR
First Name:WISANU
Middle Name:
Last Name:CHAROENKUL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14810 LAKE HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-5821
Mailing Address - Country:US
Mailing Address - Phone:425-747-9210
Mailing Address - Fax:
Practice Address - Street 1:14810 LAKE HILLS BLVD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5821
Practice Address - Country:US
Practice Address - Phone:425-747-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00097981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics