Provider Demographics
NPI:1902455694
Name:HOSPITALITY DENTAL GROUP/IRVING M. FELDKAMP III & M. BOYKO
Entity Type:Organization
Organization Name:HOSPITALITY DENTAL GROUP/IRVING M. FELDKAMP III & M. BOYKO
Other - Org Name:HOSPITALITY DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSUE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-723-1044
Mailing Address - Street 1:PO BOX 10669
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0669
Mailing Address - Country:US
Mailing Address - Phone:909-723-1013
Mailing Address - Fax:
Practice Address - Street 1:164 W HOSPITALITY LN STE 14
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3329
Practice Address - Country:US
Practice Address - Phone:909-888-7817
Practice Address - Fax:909-495-1315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherN/A