Healthcare Provider Details

I. General information

NPI: 1740348994
Provider Name (Legal Business Name): CORACEL SURATOS TEMPLO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 05/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9349 FOOTHILL BLVD STE B
RANCHO CUCAMONGA CA
91730-3567
US

IV. Provider business mailing address

9349 FOOTHILL BLVD STE B
RANCHO CUCAMONGA CA
91730-3567
US

V. Phone/Fax

Practice location:
  • Phone: 909-980-6363
  • Fax:
Mailing address:
  • Phone: 909-980-6363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number45536
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: