Provider Demographics
NPI:1164986113
Name:ITARUT DENTAL LLC
Entity Type:Organization
Organization Name:ITARUT DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORGANIZER
Authorized Official - Prefix:DR
Authorized Official - First Name:PIYANUT
Authorized Official - Middle Name:
Authorized Official - Last Name:ITARUT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:618-977-6071
Mailing Address - Street 1:3756 LA VISTA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5642
Mailing Address - Country:US
Mailing Address - Phone:404-636-4700
Mailing Address - Fax:
Practice Address - Street 1:3756 LA VISTA RD
Practice Address - Street 2:SUITE 102
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-5642
Practice Address - Country:US
Practice Address - Phone:404-636-4700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-24
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental