Provider Demographics
NPI:1568082030
Name:POLPORNVITOON, PHENNATDA
Entity Type:Individual
Prefix:
First Name:PHENNATDA
Middle Name:
Last Name:POLPORNVITOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18000 TOLEDO BLADE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT CHARLOTTE
Mailing Address - State:FL
Mailing Address - Zip Code:33948-1980
Mailing Address - Country:US
Mailing Address - Phone:954-383-8362
Mailing Address - Fax:
Practice Address - Street 1:18000 TOLEDO BLADE BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33948-1980
Practice Address - Country:US
Practice Address - Phone:941-740-8598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-24
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN25388122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist