MEDICARE: KITTY HAWK SMILES DENTISTRY AND ORTHODONTICS, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1245599539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KITTY HAWK SMILES DENTISTRY AND ORTHODONTICS, PC

Provider Business Mailing Address
First Line	:	17000 RED HILL AVE
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92614-5626
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	902 KITTY HAWK RD
Second Line	:	SUITE 100
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-3825
Country	:	US
Telephone Number	:	210-566-5599
Fax Number	:	210-566-4972

Authorized Official
Title or Position	:	DDS- OWNER
Name	:	JOHN S BARNES
Credential	:
Telephone Number	:	210-566-5599

Provider Enumeration Date	:	05/08/2012
Last Update Date	:	11/12/2013

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