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General NPI Number Information
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NPI Number | 1407530918
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Entity Type | Organization
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Legal Business Name | SOCAL DENTAL SPECIALISTS DENTAL GROUP OF DR. UMMETHALA
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Dates
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Enumeration Date | 06/14/2023
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Last Update Date | 06/14/2023
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Provider Practice Location Address
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Address Line | 1460 FORD ST. STE 105
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City | REDLANDS
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State | CA
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Zip | 92373
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Country | US
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Telephone | 909-500-2705
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Fax | 909-500-3930
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Provider Business Mailing Address
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Address Line | 1461 FORD ST. STE 105
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City | REDLANDS
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State | CA
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Zip | 92373
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Country | US
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Telephone | 909-500-2705
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Fax | 909-500-3930
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. KITICHAI RUNGCHARASSAENG
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Credential | DDS
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Telephone | 909-500-2705
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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