Provider Demographics
NPI:1720716350
Name:SERBAS, KELGYNN SIA (DMD)
Entity type:Individual
Prefix:DR
First Name:KELGYNN
Middle Name:SIA
Last Name:SERBAS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12460 CALIFORNIA ST
Mailing Address - Street 2:#1409
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:27949 GREENSPOT RD
Practice Address - Street 2:STE H
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346
Practice Address - Country:US
Practice Address - Phone:909-864-6010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS109764122300000X
GADN122699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist