Provider Demographics
NPI:1730266974
Name:SIRIWAT, P.PENNY (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:P.PENNY
Middle Name:
Last Name:SIRIWAT
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 S BEACH BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-1812
Mailing Address - Country:US
Mailing Address - Phone:714-527-9006
Mailing Address - Fax:714-527-5681
Practice Address - Street 1:515 S BEACH BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-1812
Practice Address - Country:US
Practice Address - Phone:714-527-9006
Practice Address - Fax:714-527-5681
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329941223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB32994-01Medicaid
CACGP#169380OtherCALIFORNIA CHILDREN SERVI
CA32994OtherDENTAL LICENSE
CAB32994-02Medicaid