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General NPI Number Information
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NPI Number | 1124423066
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Entity Type | Organization
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Legal Business Name | SIMONA D. KISS D.D.S. PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 11/04/2014
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Last Update Date | 11/04/2014
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Provider Practice Location Address
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Address Line | 18102 IRVINE BLVD STE 201
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City | TUSTIN
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State | CA
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Zip | 92780-3424
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Country | US
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Telephone | 714-730-9656
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Fax |
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Provider Business Mailing Address
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Address Line | 18102 IRVINE BLVD STE 201
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City | TUSTIN
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State | CA
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Zip | 92780-3424
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST, DIRECTOR
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Name | DR. SIMONA KISS
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Credential |
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Telephone | 714-730-9656
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 46399
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License Number State | CA
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