Provider Demographics
NPI:1437347101
Name:THANASASAVAT, SIRIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SIRIN
Middle Name:
Last Name:THANASASAVAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8010 SUNPORT DR STE 115
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-7897
Mailing Address - Country:US
Mailing Address - Phone:407-412-7887
Mailing Address - Fax:407-930-2758
Practice Address - Street 1:8010 SUNPORT DR STE 115
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-7897
Practice Address - Country:US
Practice Address - Phone:407-412-7887
Practice Address - Fax:407-930-2758
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN179891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076828600Medicaid