Provider Demographics
NPI:1376987636
Name:LAOWANSIRI, UTUMPORN (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:UTUMPORN
Middle Name:
Last Name:LAOWANSIRI
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:DR
Other - First Name:PENNY
Other - Middle Name:
Other - Last Name:LAOWANSIRI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS, MS
Mailing Address - Street 1:4150 EASTGATE DR APT 8203
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-5238
Mailing Address - Country:US
Mailing Address - Phone:314-541-9377
Mailing Address - Fax:
Practice Address - Street 1:3311 DANIELS RD STE 104
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-7000
Practice Address - Country:US
Practice Address - Phone:407-656-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 200171223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics