MEDICARE: KOKA DENTAL CORPORATION

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	261QD0000X	Dental Clinic/Center	63470	CA

General Provider Information

NPI Number	:	1346626066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KOKA DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	8031 LINDA VISTA RD
Second Line	:	SUITE 210
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-5110
Country	:	US
Telephone Number	:	858-268-5020
Fax Number	:	858-268-5030

Provider Business Practice Location Address
First Line	:	8031 LINDA VISTA RD
Second Line	:	SUITE 210
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-5110
Country	:	US
Telephone Number	:	858-268-5020
Fax Number	:	858-268-5030

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SREENIVAS KOKA
Credential	:	DDS, PHD
Telephone Number	:	858-268-5020

Provider Enumeration Date	:	08/04/2015
Last Update Date	:	08/04/2015

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Directions to “KOKA DENTAL CORPORATION ” Practice Location

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