Healthcare Provider Details

I. General information

NPI: 1982124624
Provider Name (Legal Business Name): KELLY KABAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32124 PASEO ADELANTO STE 2
SAN JUAN CAPISTRANO CA
92675-3636
US

IV. Provider business mailing address

32124 PASEO ADELANTO STE 2
SAN JUAN CAPISTRANO CA
92675-3636
US

V. Phone/Fax

Practice location:
  • Phone: 949-496-5585
  • Fax:
Mailing address:
  • Phone: 949-496-5585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number101454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: