Provider Demographics
NPI:1295215168
Name:KANOKNUCH SHIFLETT DENTAL CORP
Entity Type:Organization
Organization Name:KANOKNUCH SHIFLETT DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KANOKNUCH
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIFLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-991-3544
Mailing Address - Street 1:906 S SUNSET AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-3400
Mailing Address - Country:US
Mailing Address - Phone:626-480-1543
Mailing Address - Fax:626-480-0622
Practice Address - Street 1:906 S SUNSET AVE STE 105
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-3400
Practice Address - Country:US
Practice Address - Phone:626-480-1543
Practice Address - Fax:626-480-0622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty