Provider Demographics
NPI:1407530918
Name:SOCAL DENTAL SPECIALISTS DENTAL GROUP OF DR. UMMETHALA
Entity Type:Organization
Organization Name:SOCAL DENTAL SPECIALISTS DENTAL GROUP OF DR. UMMETHALA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KITICHAI
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNGCHARASSAENG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-500-2705
Mailing Address - Street 1:1461 FORD ST.
Mailing Address - Street 2:STE 105
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373
Mailing Address - Country:US
Mailing Address - Phone:909-500-2705
Mailing Address - Fax:909-500-3930
Practice Address - Street 1:1460 FORD ST.
Practice Address - Street 2:STE 105
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-500-2705
Practice Address - Fax:909-500-3930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty