Provider Demographics
NPI:1700220043
Name:ATSAWASUWAN, PHIMON
Entity Type:Individual
Prefix:DR
First Name:PHIMON
Middle Name:
Last Name:ATSAWASUWAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1283 W. WESTGATE TERRACE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607
Mailing Address - Country:US
Mailing Address - Phone:312-928-9728
Mailing Address - Fax:815-293-2159
Practice Address - Street 1:1283 W. WESTGATE TERRACE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607
Practice Address - Country:US
Practice Address - Phone:312-928-9728
Practice Address - Fax:815-293-2159
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190288771223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics