1932553633 NPI number — KERI KM DENTAL GROUP, A PROFESSIONAL GROUP

Table of content: (NPI 1932553633)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932553633 NPI number — KERI KM DENTAL GROUP, A PROFESSIONAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KERI KM DENTAL GROUP, A PROFESSIONAL GROUP
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:
6
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:
1932553633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9737 AERO DR STE 210
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92123-1859
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-585-8500
Provider Business Mailing Address Fax Number:
619-362-9923

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9737 AERO DR STE 210
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:
92123-1859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-585-8500
Provider Business Practice Location Address Fax Number:
619-362-9923
Provider Enumeration Date:
04/19/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FLORES
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
ELENA
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
619-869-1149

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  42542 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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