Healthcare Provider Details

I. General information

NPI: 1114220902
Provider Name (Legal Business Name): SUMATHI CHANDRASHEKHAR,DMD,A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18523 CORWIN RD STE C
APPLE VALLEY CA
92307-2300
US

IV. Provider business mailing address

18523 CORWIN RD STE C
APPLE VALLEY CA
92307-2300
US

V. Phone/Fax

Practice location:
  • Phone: 760-884-3764
  • Fax:
Mailing address:
  • Phone: 760-884-3764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number56055
License Number StateCA

VIII. Authorized Official

Name: DR. SUMATHI CHANDRASHEKHAR
Title or Position: CEO
Credential: DMD
Phone: 760-628-5664