Provider Demographics
NPI:1063220101
Name:MDG-KITTO DENTAL PC
Entity type:Organization
Organization Name:MDG-KITTO DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-592-4360
Mailing Address - Street 1:937 E MAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5309
Mailing Address - Country:US
Mailing Address - Phone:805-922-4109
Mailing Address - Fax:
Practice Address - Street 1:937 E MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5309
Practice Address - Country:US
Practice Address - Phone:805-922-4109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-20
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty