Provider Demographics
NPI:1891402079
Name:KIATKACHORN RATANATHARATHORN, DDS INC
Entity Type:Organization
Organization Name:KIATKACHORN RATANATHARATHORN, DDS INC
Other - Org Name:NU DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIATKACHORN
Authorized Official - Middle Name:
Authorized Official - Last Name:RATANATHARATHORN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-375-5671
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental