Provider Demographics
NPI:1093959207
Name:SEKHAR CHAKKA DENTAL CORP
Entity Type:Organization
Organization Name:SEKHAR CHAKKA DENTAL CORP
Other - Org Name:STADIUM DENTAL AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SEKHAR
Authorized Official - Middle Name:N
Authorized Official - Last Name:CHAKKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-476-9678
Mailing Address - Street 1:11897 FOOTHILL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-476-9678
Mailing Address - Fax:909-481-0040
Practice Address - Street 1:11897 FOOTHILL BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-476-9678
Practice Address - Fax:909-481-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-01
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47856122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty