Healthcare Provider Details

I. General information

NPI: 1104074400
Provider Name (Legal Business Name): KINGSBURG FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1064 LEWIS ST
KINGSBURG CA
93631
US

IV. Provider business mailing address

1064 LEWIS ST
KINGSBURG CA
93631
US

V. Phone/Fax

Practice location:
  • Phone: 559-897-2600
  • Fax: 559-897-2622
Mailing address:
  • Phone: 559-897-2600
  • Fax: 559-897-2622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. VEROCK SEAN KY
Title or Position: GENERAL DENTIST
Credential: D.D.S.
Phone: 559-897-2600