Provider Demographics
NPI:1790137859
Name:SONCHAIWANICH, KEITH CHATREE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:CHATREE
Last Name:SONCHAIWANICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12786 150TH CT N
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33478-3579
Mailing Address - Country:US
Mailing Address - Phone:561-222-1209
Mailing Address - Fax:
Practice Address - Street 1:6035 SE FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-8104
Practice Address - Country:US
Practice Address - Phone:772-223-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 220511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice