Provider Demographics
NPI:1477079531
Name:MANORAK, WICHAYAPHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:WICHAYAPHA
Middle Name:
Last Name:MANORAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 CHESTNUT ST
Mailing Address - Street 2:702
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-3621
Mailing Address - Country:US
Mailing Address - Phone:215-554-0388
Mailing Address - Fax:
Practice Address - Street 1:3608 FOREST DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1043
Practice Address - Country:US
Practice Address - Phone:215-554-0388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401415789122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist