Healthcare Provider Details

I. General information

NPI: 1215077508
Provider Name (Legal Business Name): REENA KHULLAR DDS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 04/26/2022
Certification Date: 04/26/2022
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 TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number49562
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: