Provider Demographics
NPI:1124184825
Name:SUKIASYAN PROFESSIONAL DENTAL CORP
Entity Type:Organization
Organization Name:SUKIASYAN PROFESSIONAL DENTAL CORP
Other - Org Name:GROVEDENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ARSEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUKIASYAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-291-8625
Mailing Address - Street 1:8283 GROVE AVE
Mailing Address - Street 2:SUITE 208
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3137
Mailing Address - Country:US
Mailing Address - Phone:909-291-8625
Mailing Address - Fax:909-291-8629
Practice Address - Street 1:8283 GROVE AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3137
Practice Address - Country:US
Practice Address - Phone:909-291-8625
Practice Address - Fax:909-291-8629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49999122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92938Medicaid