Provider Demographics
NPI:1356149009
Name:SANTA FE SPRINGS MODERN DENTISTRY, INC
Entity type:Organization
Organization Name:SANTA FE SPRINGS MODERN DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHADY
Authorized Official - Middle Name:
Authorized Official - Last Name:KEROLLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-845-8500
Mailing Address - Street 1:PO BOX 660041
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13327 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670
Practice Address - Country:US
Practice Address - Phone:562-232-4715
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty