Basic Information
| Provider Information | |||||||||
| NPI: | 1538774948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIAO | ||||||||
| FirstName: | KE | ||||||||
| MiddleName: | DONG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9837 LA VINE CT | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917015952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095395835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2450 CRAVEN ST # 3300 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921365599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195568101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2020 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 105503 | CA | Y | Dental Providers | Dentist |
No ID Information.