Healthcare Provider Details

I. General information

NPI: 1114313566
Provider Name (Legal Business Name): KELLEY HOANG DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/13/2022
Certification Date: 07/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3991 GRAND AVE STE D
CHINO CA
91710-5442
US

IV. Provider business mailing address

3991 GRAND AVE STE D
CHINO CA
91710-5442
US

V. Phone/Fax

Practice location:
  • Phone: 714-345-4253
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number057374
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number105831
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: