Provider Demographics
NPI:1497924997
Name:SOUTHRIDGE DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTHRIDGE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-822-9090
Mailing Address - Street 1:14050 CHERRY AVE
Mailing Address - Street 2:STE. A
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-0766
Mailing Address - Country:US
Mailing Address - Phone:909-822-9090
Mailing Address - Fax:909-822-9094
Practice Address - Street 1:14050 CHERRY AVE
Practice Address - Street 2:STE. A
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-0766
Practice Address - Country:US
Practice Address - Phone:909-822-9090
Practice Address - Fax:909-822-9094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-28
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty