Healthcare Provider Details

I. General information

NPI: 1699842492
Provider Name (Legal Business Name): ETEMADI DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12729 FOOTHILL BLVD SUITE # A
RANCHO CUCAMONGA CA
91739-9334
US

IV. Provider business mailing address

12729 FOOTHILL BLVD SUITE # A
RANCHO CUCAMONGA CA
91739-9334
US

V. Phone/Fax

Practice location:
  • Phone: 909-899-8757
  • Fax: 909-899-8760
Mailing address:
  • Phone: 909-899-8757
  • Fax: 909-899-8760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KHASHAYAR ETEMADI
Title or Position: PRESIDENT
Credential: DDS
Phone: 909-899-8757