Provider Demographics
NPI:1174621213
Name:KIS, JOHN IHOR (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:IHOR
Last Name:KIS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 30TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2713
Mailing Address - Country:US
Mailing Address - Phone:650-345-1773
Mailing Address - Fax:
Practice Address - Street 1:1500 SOUTHGATE AVE STE 210
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2231
Practice Address - Country:US
Practice Address - Phone:650-756-0938
Practice Address - Fax:650-756-1915
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0334821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice