Provider Demographics
NPI:1114313566
Name:HOANG, KELLEY (DDS)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HOANG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3991 GRAND AVE STE D
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5442
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3991 GRAND AVE STE D
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5442
Practice Address - Country:US
Practice Address - Phone:714-345-4253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057374122300000X
CA1058311223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist