Healthcare Provider Details

I. General information

NPI: 1295465367
Provider Name (Legal Business Name): KATCHOOI DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12630 MONTE VISTA RD STE 108
POWAY CA
92064-2526
US

IV. Provider business mailing address

7814 INCEPTION WAY
SAN DIEGO CA
92108-5122
US

V. Phone/Fax

Practice location:
  • Phone: 858-312-5242
  • Fax:
Mailing address:
  • Phone: 478-390-1960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MINA KATCHOOI
Title or Position: OWNER
Credential: DDS
Phone: 478-390-1960