Provider Demographics
NPI:1326391095
Name:KARN KRITSANACHAIWANICH PA
Entity Type:Organization
Organization Name:KARN KRITSANACHAIWANICH PA
Other - Org Name:WESTERN TRAILS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KARN
Authorized Official - Middle Name:
Authorized Official - Last Name:KRITSANACHAIWANICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-326-2066
Mailing Address - Street 1:2312 WESTERN TRAILS BLVD
Mailing Address - Street 2:104-A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-1642
Mailing Address - Country:US
Mailing Address - Phone:512-326-2066
Mailing Address - Fax:512-326-2955
Practice Address - Street 1:2312 WESTERN TRAILS BLVD
Practice Address - Street 2:104-A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-1642
Practice Address - Country:US
Practice Address - Phone:512-326-2066
Practice Address - Fax:512-326-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17673122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty