=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508126731
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLI JUNKER DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2012
-----------------------------------------------------
Last Update Date | 05/22/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 NEWPORT CENTER DRIVE #708
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-8604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 NEWPORT CENTER DRIVE #708
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-8604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-640-2970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLI JUNKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-420-0546
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 51160
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------