MEDICARE: KIDS DENTAL KARE

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	G89849-01	CA

General Provider Information

NPI Number	:	1952435885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS DENTAL KARE

Provider Business Mailing Address
First Line	:	10900 LONG BEACH BLVD
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-2514
Country	:	US
Telephone Number	:	310-632-0202
Fax Number	:

Provider Business Practice Location Address
First Line	:	10900 LONG BEACH BLVD
Second Line	:
City	:	LYNWOOD
State	:	CA
Zip	:	90262-2514
Country	:	US
Telephone Number	:	310-632-0202
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEENA JACOB
Credential	:
Telephone Number	:	888-543-7336

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	08/12/2008

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