Provider Demographics
NPI:1972603421
Name:KELK, PICHAK (DDS)
Entity Type:Individual
Prefix:MS
First Name:PICHAK
Middle Name:
Last Name:KELK
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 1:1111 TOWN & COUNTRY RD.
Mailing Address - Street 2:SUITE 46
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868
Mailing Address - Country:US
Mailing Address - Phone:714-835-4441
Mailing Address - Fax:714-835-0188
Practice Address - Street 1:1111 TOWN & COUNTRY RD.
Practice Address - Street 2:SUITE 46
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-835-4441
Practice Address - Fax:714-835-0188
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA434501223P0300X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics