Healthcare Provider Details

I. General information

NPI: 1720017569
Provider Name (Legal Business Name): CANDICE LYNN KAMINSKI D.D.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16466 BERNARDO CENTER DR STE 176
SAN DIEGO CA
92128-2522
US

IV. Provider business mailing address

6307 CAMINITO DEL PASTEL
SAN DIEGO CA
92111-6825
US

V. Phone/Fax

Practice location:
  • Phone: 858-676-6709
  • Fax:
Mailing address:
  • Phone: 619-957-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12396
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number56629
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: