Provider Demographics
NPI:1205853157
Name:WANGWONGVIVAT, JIRAVAT (DDS)
Entity Type:Individual
Prefix:DR
First Name:JIRAVAT
Middle Name:
Last Name:WANGWONGVIVAT
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 1:12724 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91605-5031
Mailing Address - Country:US
Mailing Address - Phone:818-765-8280
Mailing Address - Fax:818-765-8454
Practice Address - Street 1:12724 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91605-5031
Practice Address - Country:US
Practice Address - Phone:818-765-8280
Practice Address - Fax:818-765-8454
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA240201OtherDELTA DENTAL
CAB40201OtherDENTI-CAL