Provider Demographics
NPI:1548675176
Name:VANICHVATANA, SOMKAMOL (DDS)
Entity type:Individual
Prefix:
First Name:SOMKAMOL
Middle Name:
Last Name:VANICHVATANA
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 1:18 S KINGSHIGHWAY BLVD
Mailing Address - Street 2:APT 9S
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-1356
Mailing Address - Country:US
Mailing Address - Phone:314-550-6780
Mailing Address - Fax:
Practice Address - Street 1:3320 RUTGER ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1122
Practice Address - Country:US
Practice Address - Phone:314-977-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program