Healthcare Provider Details

I. General information

NPI: 1770593113
Provider Name (Legal Business Name): KENNETH KON HSU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15845 CHANNEL ST SUITE A
SAN LORENZO CA
94580-1441
US

IV. Provider business mailing address

15845 CHANNEL ST SUITE A
SAN LORENZO CA
94580-1441
US

V. Phone/Fax

Practice location:
  • Phone: 510-276-3711
  • Fax:
Mailing address:
  • Phone: 510-276-3711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number40247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: