Healthcare Provider Details

I. General information

NPI: 1003262502
Provider Name (Legal Business Name): REENA KHULLAR DDS AND PUNEET WADHWA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2016
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3055 S ARCHIBALD AVE STE C-1
ONTARIO CA
91761-9007
US

IV. Provider business mailing address

1928 ANO NUEVO DR
DIAMOND BAR CA
91765-2950
US

V. Phone/Fax

Practice location:
  • Phone: 909-466-4611
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number49562
License Number StateCA

VIII. Authorized Official

Name: REENA KHULLAR
Title or Position: OWNER
Credential:
Phone: 909-996-0523