Healthcare Provider Details

I. General information

NPI: 1164767125
Provider Name (Legal Business Name): KALIKA-IVERSON CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2012
Last Update Date: 12/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 RALEY BLVD
CHICO CA
95928-8352
US

IV. Provider business mailing address

101 RALEY BLVD
CHICO CA
95928-8352
US

V. Phone/Fax

Practice location:
  • Phone: 530-671-2940
  • Fax:
Mailing address:
  • Phone: 530-671-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number37283
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number45886
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number33473
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number33473
License Number StateCA

VIII. Authorized Official

Name: LEANI N. MARTINEZ
Title or Position: INS. COORDINATOR
Credential:
Phone: 916-783-5239