Healthcare Provider Details

I. General information

NPI: 1306014568
Provider Name (Legal Business Name): ANTHONY INCHOL CHA D.D.S.,M.S.,M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2008
Last Update Date: 02/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18909 SOLEDAD CANYON RD STE G
CANYON COUNTRY CA
91351-3385
US

IV. Provider business mailing address

18909 SOLEDAD CANYON RD STE G
CANYON COUNTRY CA
91351-3385
US

V. Phone/Fax

Practice location:
  • Phone: 661-251-7107
  • Fax: 661-251-8850
Mailing address:
  • Phone: 661-251-7107
  • Fax: 661-251-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number46170
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: