Provider Demographics
NPI:1750867487
Name:RATANATHARATHORN, KIATKACHORN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIATKACHORN
Middle Name:
Last Name:RATANATHARATHORN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1512
Mailing Address - Country:US
Mailing Address - Phone:626-810-2691
Mailing Address - Fax:
Practice Address - Street 1:2420 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1512
Practice Address - Country:US
Practice Address - Phone:626-810-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist