Provider Demographics
NPI:1558199257
Name:POOVARODOM, PONGSAKORN (DDS, MSC, PHD)
Entity type:Individual
Prefix:DR
First Name:PONGSAKORN
Middle Name:
Last Name:POOVARODOM
Suffix:
Gender:M
Credentials:DDS, MSC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 BILLINGS ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-6882
Mailing Address - Country:US
Mailing Address - Phone:854-858-2195
Mailing Address - Fax:
Practice Address - Street 1:173 ASHLEY AVE # MSC507
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8908
Practice Address - Country:US
Practice Address - Phone:843-792-3811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-24
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC601223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics