Healthcare Provider Details

I. General information

NPI: 1245388032
Provider Name (Legal Business Name): ARROWHEAD COMMUNITY SURGICAL MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE SURGERY DEPARTMENT
COLTON CA
92324-1801
US

IV. Provider business mailing address

PO BOX 670
REDLANDS CA
92373-0221
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-6210
  • Fax: 909-580-1363
Mailing address:
  • Phone: 909-580-6210
  • Fax: 909-580-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number51201
License Number StateCA

VIII. Authorized Official

Name: APPANAGARI GNANADEV
Title or Position: PRESIDENT
Credential: MD.
Phone: 909-580-6210