1073164141 NPI number — KIMBALL DENTAL GROUP OF MISSION VALLEY, PC

Table of content: (NPI 1073164141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073164141 NPI number — KIMBALL DENTAL GROUP OF MISSION VALLEY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBALL DENTAL GROUP OF MISSION VALLEY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073164141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31972 COAST HWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAGUNA BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92651-6762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-420-0952
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8590 RIO SAN DIEGO DR STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-5597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-299-1122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/20/2019

Additional Information

Authorized Official

Authorized Official Last Name:
PARDON
Authorized Official First Name:
TWYLA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
REGIONAL DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
714-420-0952

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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