Healthcare Provider Details

I. General information

NPI: 1376556597
Provider Name (Legal Business Name): KEVIN BRENT DORSEY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 E FLORENCE AVE
HUNTINGTON PARK CA
90255-5900
US

IV. Provider business mailing address

3512 E. FLORENCE AVE.
HUNTINGTON PARK CA
90255
US

V. Phone/Fax

Practice location:
  • Phone: 323-589-6765
  • Fax: 323-589-4154
Mailing address:
  • Phone: 310-378-6249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number37976
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: