Provider Demographics
NPI:1891837449
Name:KISSEVICH, ZSOLT HORVATH (DMD)
Entity Type:Individual
Prefix:
First Name:ZSOLT
Middle Name:HORVATH
Last Name:KISSEVICH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 N TEHAMA ST STE A
Mailing Address - Street 2:
Mailing Address - City:WILLOWS
Mailing Address - State:CA
Mailing Address - Zip Code:95988-2546
Mailing Address - Country:US
Mailing Address - Phone:650-206-0164
Mailing Address - Fax:
Practice Address - Street 1:444 N TEHAMA ST STE A
Practice Address - Street 2:
Practice Address - City:WILLOWS
Practice Address - State:CA
Practice Address - Zip Code:95988-2546
Practice Address - Country:US
Practice Address - Phone:650-206-0164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA363171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD36317Medicaid