Provider Demographics
NPI:1861992323
Name:HOSS/KERI CMV DENTAL GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:HOSS/KERI CMV DENTAL GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-636-2665
Mailing Address - Street 1:9737 AERO DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1859
Mailing Address - Country:US
Mailing Address - Phone:619-636-2665
Mailing Address - Fax:
Practice Address - Street 1:11943 EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-2597
Practice Address - Country:US
Practice Address - Phone:619-636-2665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty