Provider Demographics
NPI:1871664946
Name:CHOTIBUT, SIRIPUN (DDS)
Entity Type:Individual
Prefix:
First Name:SIRIPUN
Middle Name:
Last Name:CHOTIBUT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-1123
Mailing Address - Country:US
Mailing Address - Phone:315-946-4656
Mailing Address - Fax:315-946-6849
Practice Address - Street 1:52 BROAD ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1123
Practice Address - Country:US
Practice Address - Phone:315-946-4656
Practice Address - Fax:315-946-6849
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038075-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics