Provider Demographics
NPI:1528646965
Name:KANGVONKIT, PIMSIRI
Entity type:Individual
Prefix:
First Name:PIMSIRI
Middle Name:
Last Name:KANGVONKIT
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 1:4900 GAGE AVE APT 383
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1629
Mailing Address - Country:US
Mailing Address - Phone:646-993-6595
Mailing Address - Fax:
Practice Address - Street 1:3411 SYCAMORE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-2091
Practice Address - Country:US
Practice Address - Phone:682-233-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX371191223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty