MEDICARE: METTA SURYA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	49808	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G 93879 01	OTHER	CA	MEDI-CAL

General Provider Information

NPI Number	:	1649338948
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	METTA SURYA DDS

Provider Business Mailing Address
First Line	:	1734 N RIVERSIDE AVE
Second Line	:	#3
City	:	RIALTO
State	:	CA
Zip	:	92376-8058
Country	:	US
Telephone Number	:	909-875-1279
Fax Number	:	909-875-1592

Provider Business Practice Location Address
First Line	:	1734 N RIVERSIDE AVE
Second Line	:	#3
City	:	RIALTO
State	:	CA
Zip	:	92376-8058
Country	:	US
Telephone Number	:	909-875-1279
Fax Number	:	909-875-1592

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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