Healthcare Provider Details

I. General information

NPI: 1306156823
Provider Name (Legal Business Name): KELVIN CHOU D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6235 LUSK BLVD
SAN DIEGO CA
92121-2731
US

IV. Provider business mailing address

6235 LUSK BLVD
SAN DIEGO CA
92121-2731
US

V. Phone/Fax

Practice location:
  • Phone: 858-558-3636
  • Fax:
Mailing address:
  • Phone: 858-558-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number102140
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019028505
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: