MEDICARE: HOSS/KERI CMV DENTAL GROUP, A PROFESSIONAL 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1861992323
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOSS/KERI CMV DENTAL GROUP, A PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	9737 AERO DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-1859
Country	:	US
Telephone Number	:	619-636-2665
Fax Number	:

Provider Business Practice Location Address
First Line	:	11943 EL CAMINO REAL STE 200
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-2597
Country	:	US
Telephone Number	:	619-636-2665
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	LAURA FLORES
Credential	:
Telephone Number	:	619-636-2665

Provider Enumeration Date	:	02/20/2018
Last Update Date	:	02/20/2018

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