Healthcare Provider Details

I. General information

NPI: 1346626066
Provider Name (Legal Business Name): KOKA DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2015
Last Update Date: 08/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8031 LINDA VISTA RD SUITE 210
SAN DIEGO CA
92111-5110
US

IV. Provider business mailing address

8031 LINDA VISTA RD SUITE 210
SAN DIEGO CA
92111-5110
US

V. Phone/Fax

Practice location:
  • Phone: 858-268-5020
  • Fax: 858-268-5030
Mailing address:
  • Phone: 858-268-5020
  • Fax: 858-268-5030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number63470
License Number StateCA

VIII. Authorized Official

Name: DR. SREENIVAS KOKA
Title or Position: OWNER
Credential: DDS, PHD
Phone: 858-268-5020