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General NPI Number Information
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NPI Number | 1124184825
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Entity Type | Organization
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Legal Business Name | SUKIASYAN PROFESSIONAL DENTAL CORP
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Dates
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Enumeration Date | 12/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8283 GROVE AVE SUITE 208
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3137
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Country | US
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Telephone | 909-291-8625
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Fax | 909-291-8629
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Provider Business Mailing Address
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Address Line | 8283 GROVE AVE SUITE 208
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91730-3137
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Country | US
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Telephone | 909-291-8625
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Fax | 909-291-8629
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Authorized Official
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Title or Position | PRESIDENT
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Name | ARSEN SUKIASYAN
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Credential | D.D.S.
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Telephone | 909-291-8625
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 49999
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License Number State | CA
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