Provider Demographics
NPI:1487848511
Name:HIGHLAND VILLAGE DENTISTRY
Entity Type:Organization
Organization Name:HIGHLAND VILLAGE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHOCKALINGAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-425-8980
Mailing Address - Street 1:7291 BOULDER AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:CA
Mailing Address - Zip Code:92346-3389
Mailing Address - Country:US
Mailing Address - Phone:909-425-8980
Mailing Address - Fax:909-425-2684
Practice Address - Street 1:7291 BOULDER AVE STE 2B
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:CA
Practice Address - Zip Code:92346-3389
Practice Address - Country:US
Practice Address - Phone:909-425-8980
Practice Address - Fax:909-425-2684
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-31
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD393881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1568582534OtherNPI CHANDRA CHOCKALINGAM
CAB393388-01Medicaid