Provider Demographics
NPI:1245350826
Name:RUNGCHARASSAENG, KITICHAI (DDS)
Entity type:Individual
Prefix:DR
First Name:KITICHAI
Middle Name:
Last Name:RUNGCHARASSAENG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13063 HELEN DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7434
Mailing Address - Country:US
Mailing Address - Phone:909-910-5887
Mailing Address - Fax:
Practice Address - Street 1:LOMA LINDA UNIVERSITY SCHOOL OF DENTISTRY
Practice Address - Street 2:DEPARTMENT OF ORTHODONTICS
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-0001
Practice Address - Country:US
Practice Address - Phone:909-558-4616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA450021223P0700X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223P0700XDental ProvidersDentistProsthodontics