| Etemadi Dental Corporation | |
|
12729 Foothill Blvd Suite # A Rancho Cucamonga CA 91739-9334 | |
| (909) 899-8757 | |
| (909) 899-8760 |
| Full Name | Etemadi Dental Corporation |
|---|---|
| Speciality | Dentist |
| Location | 12729 Foothill Blvd, Rancho Cucamonga, California |
| Authorized Official Name and Position | Khashayar Etemadi (PRESIDENT) |
| Authorized Official Contact | 9098998757 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Etemadi Dental Corporation 12729 Foothill Blvd Suite # A Rancho Cucamonga CA 91739-9334 Ph: (909) 899-8757 | Etemadi Dental Corporation 12729 Foothill Blvd Suite # A Rancho Cucamonga CA 91739-9334 Ph: (909) 899-8757 |
| NPI Number | 1699842492 |
|---|---|
| Provider Enumeration Date | 11/29/2006 |
| Last Update Date | 10/13/2021 |
| Medicare PECOS PAC ID | 5799098331 |
|---|---|
| Medicare Enrollment ID | O20150724011862 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699842492 | NPI | - | NPPES |
| G9124301 | Other | CA | MEDICAL |
| 868675 | Other | CA | UNITED CONCORDIA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (* (Not Available)) | Primary |
| 1223X0400X | Dentist - Orthodontics And Dentofacial Orthopedics | (* (Not Available)) | Secondary |
| Provider Name | Khashayar Etemadi |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1538240247 PECOS PAC ID: 6608189246 Enrollment ID: I20150724011959 |
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