Provider Demographics
NPI:1093820557
Name:DEISEM, HARLEY ALBERT JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:HARLEY
Middle Name:ALBERT
Last Name:DEISEM
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12875 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4556
Mailing Address - Country:US
Mailing Address - Phone:909-591-0316
Mailing Address - Fax:909-628-4823
Practice Address - Street 1:12875 MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4556
Practice Address - Country:US
Practice Address - Phone:909-591-0316
Practice Address - Fax:909-628-4823
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0296981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice