Provider Demographics
NPI:1366688525
Name:JEFFERSON AND CHOKKA PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:JEFFERSON AND CHOKKA PROFESSIONAL DENTAL CORPORATION
Other - Org Name:HIGHLAND DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNE DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-864-6010
Mailing Address - Street 1:2860 MICHELLE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-368-2077
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:27949 GREENSPOT ROAD
Practice Address - Street 2:SUITE H
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346
Practice Address - Country:US
Practice Address - Phone:909-864-6010
Practice Address - Fax:909-864-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty