Healthcare Provider Details

I. General information

NPI: 1588570352
Provider Name (Legal Business Name): DANIEL SAMUEL KOLTA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 RANCHO VALLEY DR STE 140
POMONA CA
91766-7105
US

IV. Provider business mailing address

2071 RANCHO VALLEY DR STE 140
POMONA CA
91766-7105
US

V. Phone/Fax

Practice location:
  • Phone: 909-374-1815
  • Fax: 909-374-1042
Mailing address:
  • Phone: 909-374-1815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113611
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: