Provider Demographics
NPI:1174739700
Name:KIERIAN B. KUKLOK, MD, DDS, INC.
Entity type:Organization
Organization Name:KIERIAN B. KUKLOK, MD, DDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIERIAN
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:KUKLOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-484-6418
Mailing Address - Street 1:9912 CARMEL MOUNTAIN RD STE A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2808
Mailing Address - Country:US
Mailing Address - Phone:858-484-6418
Mailing Address - Fax:858-484-6318
Practice Address - Street 1:9912 CARMEL MOUNTAIN RD STE A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2808
Practice Address - Country:US
Practice Address - Phone:858-484-6418
Practice Address - Fax:858-484-6318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOMS291223S0112X
CAA68737174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty