Provider Demographics
NPI:1417407677
Name:HESPERIA DENTAL CENTER INC.
Entity Type:Organization
Organization Name:HESPERIA DENTAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-244-7232
Mailing Address - Street 1:16990 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-7919
Mailing Address - Country:US
Mailing Address - Phone:760-244-7232
Mailing Address - Fax:760-244-5104
Practice Address - Street 1:16990 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-7919
Practice Address - Country:US
Practice Address - Phone:760-244-7232
Practice Address - Fax:760-244-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA439051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty