Basic Information
| Provider Information | |||||||||
| NPI: | 1689733685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DO | ||||||||
| FirstName: | KENT | ||||||||
| MiddleName: | NAM | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DO | ||||||||
| OtherFirstName: | NAM | ||||||||
| OtherMiddleName: | B | ||||||||
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| OtherCredential: | DMD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17564 SANTA CATALINA CIR | ||||||||
| Address2: | |||||||||
| City: | FOUNTAIN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927084309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143763770 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3500 S BRISTOL ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927047319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149576030 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 51918 | CA | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.