Healthcare Provider Details

I. General information

NPI: 1669965604
Provider Name (Legal Business Name): BRINDHA SUBRAMANIAN, BDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23082 RIDGE ROUTE DR STE A
LAKE FOREST CA
92630-3691
US

IV. Provider business mailing address

23082 RIDGE ROUTE DR STE A
LAKE FOREST CA
92630-3691
US

V. Phone/Fax

Practice location:
  • Phone: 949-837-2766
  • Fax:
Mailing address:
  • Phone: 949-837-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number58339
License Number StateCA

VIII. Authorized Official

Name: JOHN FEHMER
Title or Position: OFFICER
Credential:
Phone: 562-577-5641