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General NPI Number Information
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NPI Number | 1912441148
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Entity Type | Organization
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Legal Business Name | SUDAN DENTAL CORPORATION
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Dates
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Enumeration Date | 12/07/2016
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 4110 EDISON AVE 107-B
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City | CHINO
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State | CA
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Zip | 91710-8409
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Country | US
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Telephone | 909-536-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 4110 EDISON AVE 107-B
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City | CHINO
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State | CA
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Zip | 91710-8409
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANISHA SUDAN
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Credential | DDS
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Telephone | 909-536-1900
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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 | 60267
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License Number State | CA
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