Provider Demographics
NPI:1568657807
Name:INTHIRAT, CHAREUNPHONE T (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAREUNPHONE
Middle Name:T
Last Name:INTHIRAT
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 1:405 ARROWHEAD BLVD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30236-1254
Mailing Address - Country:US
Mailing Address - Phone:404-545-1769
Mailing Address - Fax:
Practice Address - Street 1:405 ARROWHEAD BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1254
Practice Address - Country:US
Practice Address - Phone:404-545-1769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0136191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice