Basic Information
| Provider Information | |||||||||
| NPI: | 1437345311 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAHASAKMONTRI | ||||||||
| FirstName: | PANIDA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | MACT HEALTH BOARD INC | ||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546260 | ||||||||
| FaxNumber: | 2097361813 | ||||||||
| Practice Location | |||||||||
| Address1: | 5192 HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | MARIPOSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099660573 | ||||||||
| FaxNumber: | 2097426321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2007 | ||||||||
| LastUpdateDate: | 10/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 10/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 55984 | CA | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | D59984 | 05 | CA | MEDICAID |