Provider Demographics
NPI:1750687984
Name:POOUDOMSAK, PRANEE V
Entity Type:Individual
Prefix:DR
First Name:PRANEE
Middle Name:V
Last Name:POOUDOMSAK
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 1:1850 S WATERMAN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-2852
Mailing Address - Country:US
Mailing Address - Phone:909-890-1529
Mailing Address - Fax:909-890-1739
Practice Address - Street 1:1850 S WATERMAN AVE STE B
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-2852
Practice Address - Country:US
Practice Address - Phone:909-890-1529
Practice Address - Fax:909-890-1739
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-05
Last Update Date:2011-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38764122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist