MEDICARE: KELLEY HOANG DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	057374	NY
2	1223P0221X	Pediatric Dentistry	105831	CA

General Provider Information

NPI Number	:	1114313566
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY HOANG DDS

Provider Business Mailing Address
First Line	:	3991 GRAND AVE STE D
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3991 GRAND AVE STE D
Second Line	:
City	:	CHINO
State	:	CA
Zip	:	91710-5442
Country	:	US
Telephone Number	:	714-345-4253
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	07/13/2022

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Directions to “ KELLEY HOANG DDS” Practice Location

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