Provider Demographics
NPI:1588716575
Name:MONGKOLLUGSANA, JACKRIT (DDS)
Entity type:Individual
Prefix:
First Name:JACKRIT
Middle Name:
Last Name:MONGKOLLUGSANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 W SCHROCK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4902
Mailing Address - Country:US
Mailing Address - Phone:614-890-7005
Mailing Address - Fax:614-890-7507
Practice Address - Street 1:154 W SCHROCK RD
Practice Address - Street 2:SUITE B
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43081-4902
Practice Address - Country:US
Practice Address - Phone:614-890-7005
Practice Address - Fax:614-890-7507
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-45801223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery