Healthcare Provider Details

I. General information

NPI: 1528831781
Provider Name (Legal Business Name): SOROURS DENTAL OFFICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2023
Last Update Date: 10/31/2023
Certification Date: 10/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17185 ARROW BLVD
FONTANA CA
92335-3972
US

IV. Provider business mailing address

6633 ATLANTIC AVE
BELL CA
90201-2523
US

V. Phone/Fax

Practice location:
  • Phone: 909-587-2474
  • Fax: 909-365-4358
Mailing address:
  • Phone: 323-456-7377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. SELVANA SOROUR
Title or Position: VICE PRESIDENT
Credential: D.M.D
Phone: 310-795-3363