Provider Demographics
NPI:1457447369
Name:PHROMCHOTIKUL, THASANAVADEE (DMD)
Entity Type:Individual
Prefix:
First Name:THASANAVADEE
Middle Name:
Last Name:PHROMCHOTIKUL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:THAS
Other - Middle Name:
Other - Last Name:PHROMCHOTIKUL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:7417 SW BEAVERTON HILLSDALE HWY
Mailing Address - Street 2:#600
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-2169
Mailing Address - Country:US
Mailing Address - Phone:503-203-1311
Mailing Address - Fax:503-203-6889
Practice Address - Street 1:7417 SW BEAVERTON HILLSDALE HWY
Practice Address - Street 2:#600
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-2169
Practice Address - Country:US
Practice Address - Phone:503-203-1311
Practice Address - Fax:503-203-6889
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice