Provider Demographics
NPI:1730406075
Name:SUDHIVORASETH, KOMSON (DDS)
Entity type:Individual
Prefix:
First Name:KOMSON
Middle Name:
Last Name:SUDHIVORASETH
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 1:228 W CAMPBELL RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-3512
Mailing Address - Country:US
Mailing Address - Phone:972-633-2377
Mailing Address - Fax:972-633-2388
Practice Address - Street 1:228 W CAMPBELL RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-3512
Practice Address - Country:US
Practice Address - Phone:972-633-2377
Practice Address - Fax:972-633-2388
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice