Healthcare Provider Details

I. General information

NPI: 1679656789
Provider Name (Legal Business Name): FRED W KAMANSKY DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6529 MISSION GORGE ROAD
SAN DIEGO CA
92120-2376
US

IV. Provider business mailing address

6529 MISSION GORGE ROAD
SAN DIEGO CA
92120-2376
US

V. Phone/Fax

Practice location:
  • Phone: 619-280-8377
  • Fax: 619-280-8378
Mailing address:
  • Phone: 619-280-8377
  • Fax: 619-280-8378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number22992
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: