Provider Demographics
NPI:1144247792
Name:CHAIMATTAYOMPOL, NOPSARAN (DMD)
Entity type:Individual
Prefix:
First Name:NOPSARAN
Middle Name:
Last Name:CHAIMATTAYOMPOL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CONGRESS ST
Mailing Address - Street 2:SUITE 3E
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-0908
Mailing Address - Country:US
Mailing Address - Phone:617-328-0693
Mailing Address - Fax:617-328-0694
Practice Address - Street 1:500 CONGRESS ST
Practice Address - Street 2:SUITE 3E
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0908
Practice Address - Country:US
Practice Address - Phone:617-328-0693
Practice Address - Fax:617-328-0694
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA207891223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics