Provider Demographics
NPI:1043570658
Name:KETCHERSIDE, HOMER GARY (DDS,MS)
Entity Type:Individual
Prefix:
First Name:HOMER
Middle Name:GARY
Last Name:KETCHERSIDE
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 MAGNOLIA AVE
Mailing Address - Street 2:SUITE A1
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3119
Mailing Address - Country:US
Mailing Address - Phone:951-737-3802
Mailing Address - Fax:951-737-3937
Practice Address - Street 1:720 MAGNOLIA AVE
Practice Address - Street 2:SUITE A1
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3119
Practice Address - Country:US
Practice Address - Phone:951-737-3800
Practice Address - Fax:951-737-3937
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics