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General NPI Number Information
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NPI Number | 1699842492
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Entity Type | Organization
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Legal Business Name | ETEMADI DENTAL CORPORATION
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 10/13/2021
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Provider Practice Location Address
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Address Line | 12729 FOOTHILL BLVD SUITE # A
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91739-9334
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Country | US
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Telephone | 909-899-8757
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Fax | 909-899-8760
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Provider Business Mailing Address
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Address Line | 12729 FOOTHILL BLVD SUITE # A
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City | RANCHO CUCAMONGA
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State | CA
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Zip | 91739-9334
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Country | US
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Telephone | 909-899-8757
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Fax | 909-899-8760
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KHASHAYAR ETEMADI
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Credential | DDS
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Telephone | 909-899-8757
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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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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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