Provider Demographics
NPI:1598839383
Name:LEETRAKUL&SUWANTAMEY DENTAL PRACTICE
Entity Type:Organization
Organization Name:LEETRAKUL&SUWANTAMEY DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KASIDIT
Authorized Official - Middle Name:
Authorized Official - Last Name:SUWANTAMEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-869-8177
Mailing Address - Street 1:10909 LAKEWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-3808
Mailing Address - Country:US
Mailing Address - Phone:562-869-8177
Mailing Address - Fax:
Practice Address - Street 1:10909 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-3808
Practice Address - Country:US
Practice Address - Phone:562-869-8177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA313991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty