Healthcare Provider Details

I. General information

NPI: 1548445463
Provider Name (Legal Business Name): JERRY L KRONQUIST SUNSET DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2008
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1906 N BROADWAY
SANTA ANA CA
92706-2610
US

IV. Provider business mailing address

1906 N BROADWAY
SANTA ANA CA
92706-2610
US

V. Phone/Fax

Practice location:
  • Phone: 714-547-6671
  • Fax: 714-547-4385
Mailing address:
  • Phone: 714-547-6671
  • Fax: 714-547-4385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30388
License Number StateCA

VIII. Authorized Official

Name: MRS. JERRY LEE KRONQUIST
Title or Position: OFFICE MANAGER
Credential:
Phone: 171-454-7667