Healthcare Provider Details

I. General information

NPI: 1093959207
Provider Name (Legal Business Name): SEKHAR CHAKKA DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 10/21/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11897 FOOTHILL BLVD SUITE A
RANCHO CUCAMONGA CA
91730
US

IV. Provider business mailing address

11897 FOOTHILL BLVD SUITE A
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-476-9678
  • Fax: 909-481-0040
Mailing address:
  • Phone: 909-476-9678
  • Fax: 909-481-0040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47856
License Number StateCA

VIII. Authorized Official

Name: DR. SEKHAR N CHAKKA
Title or Position: OWNER DENTIST
Credential: DDS
Phone: 909-476-9678