Healthcare Provider Details

I. General information

NPI: 1164698379
Provider Name (Legal Business Name): MK SG DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15825 LAGUNA CANYON RD 206
IRVINE CA
92618-2125
US

IV. Provider business mailing address

18525 LAGUNA CANYON ROAD #206
IRVINE CA
92618
US

V. Phone/Fax

Practice location:
  • Phone: 949-789-8989
  • Fax: 949-453-0970
Mailing address:
  • Phone: 949-789-8989
  • Fax: 949-453-0970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateCA
# 6
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number StateCA

VIII. Authorized Official

Name: MR. SAM GILANI
Title or Position: CO-OWNER
Credential: DMD
Phone: 949-789-8989