Healthcare Provider Details

I. General information

NPI: 1033592241
Provider Name (Legal Business Name): KSL DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 12/06/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 W HOLT BLVD STE 402
ONTARIO CA
91762-3681
US

IV. Provider business mailing address

815 W HOLT BLVD STE 402
ONTARIO CA
91762-3681
US

V. Phone/Fax

Practice location:
  • Phone: 972-746-0881
  • Fax:
Mailing address:
  • Phone: 972-746-0881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47881
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NEVEIN AMER
Title or Position: PRESIDENT/OWNER
Credential: DDS
Phone: 972-746-0881