Healthcare Provider Details

I. General information

NPI: 1457966566
Provider Name (Legal Business Name): KATHERINE TALITHA ANNE VANCE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 COMMERCIAL RD STE 104
SAN BERNARDINO CA
92408-3766
US

IV. Provider business mailing address

4886 GARDENIA ST
OCEANSIDE CA
92057-5431
US

V. Phone/Fax

Practice location:
  • Phone: 909-799-9988
  • Fax:
Mailing address:
  • Phone: 218-689-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number108262
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD14482
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: