Healthcare Provider Details

I. General information

NPI: 1366355000
Provider Name (Legal Business Name): MY KID'S DENTIST OF LAKE FOREST, PROF. CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23708 EL TORO RD STE B
LAKE FOREST CA
92630-8907
US

IV. Provider business mailing address

PO BOX 660041
DALLAS TX
75266-0041
US

V. Phone/Fax

Practice location:
  • Phone: 949-234-6799
  • Fax: 949-238-2620
Mailing address:
  • Phone: 714-845-8890
  • Fax: 303-952-0892

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: GRACE NOH
Title or Position: OWNER
Credential: DDS
Phone: 949-234-6799