Provider Demographics
NPI:1689139065
Name:CORIA, KELSEY BRITTANY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:BRITTANY
Last Name:CORIA
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 1:120 C AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1992
Mailing Address - Country:US
Mailing Address - Phone:209-518-9612
Mailing Address - Fax:
Practice Address - Street 1:120 C AVE STE 100
Practice Address - Street 2:
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1992
Practice Address - Country:US
Practice Address - Phone:209-518-9612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1054801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1659768802Medicaid