Healthcare Provider Details

I. General information

NPI: 1245497932
Provider Name (Legal Business Name): INLAND EMPIRE ORAL AND MAXILLOFACIAL SURGEONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2008
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8112 MILLIKEN AVE 102
RANCHO CUCAMONGA CA
91730-7471
US

IV. Provider business mailing address

8112 MILLIKEN AVE 102
RANCHO CUCAMONGA CA
91730-7471
US

V. Phone/Fax

Practice location:
  • Phone: 909-581-7761
  • Fax: 909-581-7766
Mailing address:
  • Phone: 909-581-7761
  • Fax: 909-581-7766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number73
License Number StateCA

VIII. Authorized Official

Name: DR. MATTHEW EDWARD DUDZIAK
Title or Position: PRESIDENT
Credential: DDS, MD
Phone: 909-581-7761