Provider Demographics
NPI:1346913134
Name:KUKIRATIRAT, TANATCHA
Entity type:Individual
Prefix:
First Name:TANATCHA
Middle Name:
Last Name:KUKIRATIRAT
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 1:3425 W PETERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-3433
Mailing Address - Country:US
Mailing Address - Phone:773-256-9222
Mailing Address - Fax:
Practice Address - Street 1:3425 W PETERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-3433
Practice Address - Country:US
Practice Address - Phone:773-256-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190333071223G0001X
IL019.0333071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice