1629557517 NPI number — KETCHERSIDE DENTAL CORPORATION

Table of content: (NPI 1629557517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629557517 NPI number — KETCHERSIDE DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KETCHERSIDE DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629557517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 W STUART AVE STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REDLANDS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92374-3129
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-793-1595
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
720 MAGNOLIA AVE STE A1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORONA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92879-3119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-737-3800
Provider Business Practice Location Address Fax Number:
951-737-3937
Provider Enumeration Date:
08/10/2018

Additional Information

Authorized Official

Authorized Official Last Name:
KETCHERSIDE
Authorized Official First Name:
HOMER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-810-7167

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  28872 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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