Active NPI
Supontep Teerakanok, DDS
- Periodontics
- Boston, MA
National Provider Identifier
1871134833
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Periodontics
- License
- DL14138
- Practice address
- Henry Goldman School of Dental Medicine
635 Albany St
Boston, MA 02118 - Phone
- (617) 763-7550
- NPI assigned
- Oct 1, 2019
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Periodontics | 1223P0300X | DL14138 | MA | Primary |
Addresses
Primary practice location
Henry Goldman School of Dental Medicine
635 Albany St
Boston, MA 02118
Mailing address
18 Elba St
Brookline, MA 02446-6759
Phone (617) 763-7550
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DL14138 | MA | MD | Periodontist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1569888000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1569888000000",
"number": "1871134833",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "18 ELBA ST",
"city": "BROOKLINE",
"state": "MA",
"postal_code": "024466759",
"telephone_number": "617-763-7550"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "HENRY GOLDMAN SCHOOL OF DENTAL MEDICINE",
"address_2": "635 ALBANY ST",
"city": "BOSTON",
"state": "MA",
"postal_code": "02118",
"telephone_number": "617-763-7550"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TEERAKANOK",
"first_name": "SUPONTEP",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2019-10-01",
"last_updated": "2019-10-01",
"status": "A"
},
"taxonomies": [
{
"code": "1223P0300X",
"taxonomy_group": "",
"desc": "Dentist, Periodontics",
"state": "MA",
"license": "DL14138",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Boston, MA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 1, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.