Healthcare Provider Details

I. General information

NPI: 1952085425
Provider Name (Legal Business Name): KEVIN XU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554-850 MEDICAL CENTER DR
BIEBER CA
96009-8000
US

IV. Provider business mailing address

1282 VIEJO HILLS DR
LAKE FOREST CA
92610-3023
US

V. Phone/Fax

Practice location:
  • Phone: 253-888-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS110502
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: