Healthcare Provider Details

I. General information

NPI: 1164448064
Provider Name (Legal Business Name): KEVEN SCOTT HEROLD DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 WALNUT AVE SUITE 33
SAN DIEGO CA
92103-4978
US

IV. Provider business mailing address

306 WALNUT AVE SUITE 33
SAN DIEGO CA
92103-4978
US

V. Phone/Fax

Practice location:
  • Phone: 619-295-3456
  • Fax:
Mailing address:
  • Phone: 619-295-3456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number51590
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: