Healthcare Provider Details

I. General information

NPI: 1497145619
Provider Name (Legal Business Name): KOTHA FLAMENCO DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8860 CENTER DR STE 410
LA MESA CA
91942-7003
US

IV. Provider business mailing address

8860 CENTER DR STE 410
LA MESA CA
91942-7003
US

V. Phone/Fax

Practice location:
  • Phone: 619-493-2103
  • Fax: 619-493-2212
Mailing address:
  • Phone: 619-493-2103
  • Fax: 619-493-2212

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: DAVID CHRISTOPHER FLAMENCO
Title or Position: OWNER
Credential:
Phone: 619-493-2103