Healthcare Provider Details

I. General information

NPI: 1609800671
Provider Name (Legal Business Name): KIERIAN BRIAN KUKLOK M.D., D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9912 CARMEL MOUNTAIN RD STE A
SAN DIEGO CA
92129-2808
US

IV. Provider business mailing address

9912 CARMEL MOUNTAIN RD STE A
SAN DIEGO CA
92129-2808
US

V. Phone/Fax

Practice location:
  • Phone: 858-484-6418
  • Fax: 858-484-6318
Mailing address:
  • Phone: 858-484-6418
  • Fax: 858-484-6318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMS29
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA68737
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: