Provider Demographics
NPI:1710289947
Name:DESIGNER DENTISTRY GROUP OF RIALTO
Entity Type:Organization
Organization Name:DESIGNER DENTISTRY GROUP OF RIALTO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAFAELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DELARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-874-0323
Mailing Address - Street 1:1786 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE 5
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8059
Mailing Address - Country:US
Mailing Address - Phone:909-874-0323
Mailing Address - Fax:909-874-2984
Practice Address - Street 1:1786 N RIVERSIDE AVE
Practice Address - Street 2:SUITE 5
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8059
Practice Address - Country:US
Practice Address - Phone:909-874-0323
Practice Address - Fax:909-874-2984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA575811223G0001X
CA579301223G0001X
CA469851223G0001X
CA593181223G0001X
CA580571223G0001X
CA538321223G0001X
CA382261223P0300X
CA243581223S0112X
CA486441223X0400X
CA25296124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Single Specialty