MEDICARE: KY DENTAL PROFESSIONAL CORPORATION

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1447113519
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KY DENTAL PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 994
Second Line	:
City	:	MORRO BAY
State	:	CA
Zip	:	93443-0994
Country	:	US
Telephone Number	:	559-393-1929
Fax Number	:

Provider Business Practice Location Address
First Line	:	302 E CARSON ST STE 100
Second Line	:
City	:	CARSON
State	:	CA
Zip	:	90745-8507
Country	:	US
Telephone Number	:	559-393-1929
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	VEROCK KY
Credential	:	DDS
Telephone Number	:	559-393-1929

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/05/2025

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Directions to “KY DENTAL PROFESSIONAL CORPORATION ” Practice Location

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