Provider Demographics
NPI:1518248814
Name:SUPAKIT PEANCHITLERTKAJORN DENTAL COORPORATION
Entity Type:Organization
Organization Name:SUPAKIT PEANCHITLERTKAJORN DENTAL COORPORATION
Other - Org Name:HAYWARD BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPAKIT
Authorized Official - Middle Name:
Authorized Official - Last Name:PEANCHITLERTKAJORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-581-7851
Mailing Address - Street 1:1866 B ST STE 201
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3139
Mailing Address - Country:US
Mailing Address - Phone:510-581-7851
Mailing Address - Fax:
Practice Address - Street 1:1866 B ST STE 201
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-3139
Practice Address - Country:US
Practice Address - Phone:510-581-7851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-31
Last Update Date:2011-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA569471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033228978Medicaid