Provider Demographics
NPI:1609959873
Name:VACHARAKIAT, MALISSA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MALISSA
Middle Name:
Last Name:VACHARAKIAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 S FREMONT AVE APT 433
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-4300
Mailing Address - Country:US
Mailing Address - Phone:210-391-6295
Mailing Address - Fax:
Practice Address - Street 1:6526 GUNN HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-4022
Practice Address - Country:US
Practice Address - Phone:813-374-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2016-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN164681223E0200X
TX217291223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics