Healthcare Provider Details

I. General information

NPI: 1891467940
Provider Name (Legal Business Name): CHEEMA DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 STANDIFORD AVE BLDG 1A
MODESTO CA
95350-6534
US

IV. Provider business mailing address

1700 STANDIFORD AVE BLDG 1A
MODESTO CA
95350-6534
US

V. Phone/Fax

Practice location:
  • Phone: 209-916-1700
  • Fax:
Mailing address:
  • Phone: 209-916-1700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JASBIR S CHEEMA
Title or Position: CEO
Credential:
Phone: 209-824-1940