Provider Demographics
NPI:1538653704
Name:KOKANOUTRANON, ANDREW (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:KOKANOUTRANON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22015 N 28TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-8222
Mailing Address - Country:US
Mailing Address - Phone:949-232-7309
Mailing Address - Fax:
Practice Address - Street 1:7448 W GLENDALE AVE STE 126
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2546
Practice Address - Country:US
Practice Address - Phone:623-930-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010057122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist