Provider Demographics
NPI:1265868780
Name:SIVAVAJCHAIPONG, ANDREA (DDS)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SIVAVAJCHAIPONG
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 1:1415 PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401
Mailing Address - Country:US
Mailing Address - Phone:541-344-8302
Mailing Address - Fax:541-343-3494
Practice Address - Street 1:1415 PEARL STREET
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-344-8302
Practice Address - Fax:541-343-3494
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62969122300000X
ORD111651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist