=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356046221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL KIROLLOS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2023
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4972 LAKEVIEW AVE
-----------------------------------------------------
City | YORBA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92886-4158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-873-7775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 OXFORD
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92612-2649
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-873-7775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 110566
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------