Provider Demographics
NPI:1003424920
Name:KRITSANACHAIWANICH, WARREN (DMD)
Entity type:Individual
Prefix:DR
First Name:WARREN
Middle Name:
Last Name:KRITSANACHAIWANICH
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 1:1524 FERRARI DR
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-3899
Mailing Address - Country:US
Mailing Address - Phone:770-906-4175
Mailing Address - Fax:
Practice Address - Street 1:3466 COBB PKWY NW STE 170
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-5768
Practice Address - Country:US
Practice Address - Phone:770-203-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-16
Last Update Date:2024-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363231223G0001X
GADN1233591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice