Provider Demographics
NPI:1558884239
Name:POULSEN DENTAL CORPORATION
Entity Type:Organization
Organization Name:POULSEN DENTAL CORPORATION
Other - Org Name:MENIFEE LAKES DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:POULSEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KYLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-228-9296
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:714-845-8500
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:29121 NEWPORT ROAD, STE 1
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584
Practice Address - Country:US
Practice Address - Phone:951-228-9296
Practice Address - Fax:951-905-1264
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-25
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty