Provider Demographics
NPI:1063250827
Name:SRIMUANG, WARISARA
Entity type:Individual
Prefix:
First Name:WARISARA
Middle Name:
Last Name:SRIMUANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5895 CEDAR MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-7840
Mailing Address - Country:US
Mailing Address - Phone:626-689-9212
Mailing Address - Fax:
Practice Address - Street 1:10470 FOOTHILL BLVD STE 126
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6945
Practice Address - Country:US
Practice Address - Phone:909-989-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26239124Q00000X
ORH8696124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist