Provider Demographics
NPI:1629557517
Name:KETCHERSIDE DENTAL CORPORATION
Entity Type:Organization
Organization Name:KETCHERSIDE DENTAL CORPORATION
Other - Org Name:PACKING HOUSE DISTRICT DENTAL & ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOMER
Authorized Official - Middle Name:
Authorized Official - Last Name:KETCHERSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-810-7167
Mailing Address - Street 1:400 W STUART AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-3129
Mailing Address - Country:US
Mailing Address - Phone:909-793-1595
Mailing Address - Fax:
Practice Address - Street 1:720 MAGNOLIA AVE STE A1
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3119
Practice Address - Country:US
Practice Address - Phone:951-737-3800
Practice Address - Fax:951-737-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-10
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900937804OtherTIN