Provider Demographics
NPI:1154820686
Name:KEVIN B. DORSEY DDS INC., A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:KEVIN B. DORSEY DDS INC., A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:213-500-1152
Mailing Address - Street 1:3512 E FLORENCE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-5900
Mailing Address - Country:US
Mailing Address - Phone:323-589-8507
Mailing Address - Fax:323-589-4154
Practice Address - Street 1:3512 E FLORENCE AVE STE 204
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-5900
Practice Address - Country:US
Practice Address - Phone:323-589-8507
Practice Address - Fax:323-589-4154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-10
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA379761223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty