Provider Demographics
NPI:1124423066
Name:SIMONA D. KISS D.D.S. PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:SIMONA D. KISS D.D.S. PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SIMONA
Authorized Official - Middle Name:
Authorized Official - Last Name:KISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-730-9656
Mailing Address - Street 1:18102 IRVINE BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3424
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18102 IRVINE BLVD STE 201
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3424
Practice Address - Country:US
Practice Address - Phone:714-730-9656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46399305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization