Provider Demographics
NPI:1164851747
Name:CHANCHAI SANGSURASAK, DDS INC.
Entity Type:Organization
Organization Name:CHANCHAI SANGSURASAK, DDS INC.
Other - Org Name:LA SIERRA FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANCHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:SANGSURASAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-354-9550
Mailing Address - Street 1:3410 LA SIERRA AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5270
Mailing Address - Country:US
Mailing Address - Phone:951-354-9550
Mailing Address - Fax:951-354-8644
Practice Address - Street 1:3410 LA SIERRA AVE
Practice Address - Street 2:SUITE D
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5270
Practice Address - Country:US
Practice Address - Phone:951-354-9550
Practice Address - Fax:951-354-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-05
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58501122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty