Provider Demographics
NPI:1104225994
Name:KANTARIS, KAELY
Entity type:Individual
Prefix:
First Name:KAELY
Middle Name:
Last Name:KANTARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4565 48TH STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4435 EASTGATE MALL #125
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-5191
Practice Address - Country:US
Practice Address - Phone:858-546-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1000988-15122300000X
FLDN27647122300000X
CADDS108191122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist