MEDICARE: JERRY L KRONQUIST SUNSET DENTAL GROUP INC

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	30388	CA
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1548445463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY L KRONQUIST SUNSET DENTAL GROUP INC

Provider Business Mailing Address
First Line	:	1906 N BROADWAY
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92706-2610
Country	:	US
Telephone Number	:	714-547-6671
Fax Number	:	714-547-4385

Provider Business Practice Location Address
First Line	:	1906 N BROADWAY
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92706-2610
Country	:	US
Telephone Number	:	714-547-6671
Fax Number	:	714-547-4385

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. JERRY LEE KRONQUIST
Credential	:
Telephone Number	:	171-454-7667

Provider Enumeration Date	:	01/09/2008
Last Update Date	:	08/11/2022

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