Provider Demographics
NPI:1497121222
Name:ITARUT, PIYANUT (DMD)
Entity Type:Individual
Prefix:
First Name:PIYANUT
Middle Name:
Last Name:ITARUT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:POM
Other - Middle Name:
Other - Last Name:ITARUT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:3756 LA VISTA RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-5642
Mailing Address - Country:US
Mailing Address - Phone:404-636-4700
Mailing Address - Fax:
Practice Address - Street 1:6474 MCABEE RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-4518
Practice Address - Country:US
Practice Address - Phone:618-977-6071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-16
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN015017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist