Provider Demographics
NPI:1932501640
Name:K KOHANI D D S A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:K KOHANI D D S A PROFESSIONAL CORPORATION
Other - Org Name:COSTA VERDE DENTISTRY & ORTHODONIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:1858-622-1007
Mailing Address - Street 1:4510 EXECUTIVE DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-3021
Mailing Address - Country:US
Mailing Address - Phone:858-622-1007
Mailing Address - Fax:858-622-1058
Practice Address - Street 1:4510 EXECUTIVE DR
Practice Address - Street 2:SUITE 205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3021
Practice Address - Country:US
Practice Address - Phone:858-622-1007
Practice Address - Fax:858-622-1058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-24
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1972710663OtherMEDICARE NPI