Provider Demographics
NPI:1275287112
Name:PUT6395 PLLC
Entity Type:Organization
Organization Name:PUT6395 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PUNYAWAT
Authorized Official - Middle Name:
Authorized Official - Last Name:LAOHAKANJANASIRI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:571-249-2839
Mailing Address - Street 1:44347 BABBLING BROOK TER APT 302
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-5023
Mailing Address - Country:US
Mailing Address - Phone:571-249-2839
Mailing Address - Fax:
Practice Address - Street 1:12005 SUNRISE VALLEY DR STE 130
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3468
Practice Address - Country:US
Practice Address - Phone:571-249-2839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty