Provider Demographics
NPI:1801461561
Name:PRIYAWAT AND KIM DENTAL SERVICES
Entity type:Organization
Organization Name:PRIYAWAT AND KIM DENTAL SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BANNATZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-497-9449
Mailing Address - Street 1:15911 POMONA RINCON RD STE 120
Mailing Address - Street 2:
Mailing Address - City:CHINO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91709-5567
Mailing Address - Country:US
Mailing Address - Phone:909-497-9449
Mailing Address - Fax:
Practice Address - Street 1:15911 POMONA RINCON RD STE 120
Practice Address - Street 2:
Practice Address - City:CHINO HILLS
Practice Address - State:CA
Practice Address - Zip Code:91709-5567
Practice Address - Country:US
Practice Address - Phone:909-497-9449
Practice Address - Fax:844-600-4099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA65123OtherDENTAL LICENSE