Provider Demographics
NPI:1902432933
Name:ASADAMONGKOL, BRALIPISUT (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRALIPISUT
Middle Name:
Last Name:ASADAMONGKOL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 TEDFORD WAY
Mailing Address - Street 2:
Mailing Address - City:MONTEREY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754-2522
Mailing Address - Country:US
Mailing Address - Phone:909-255-5736
Mailing Address - Fax:
Practice Address - Street 1:5065 HOLLYWOOD BLVD STE 205
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6122
Practice Address - Country:US
Practice Address - Phone:323-666-9881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1039091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice