Provider Demographics
NPI:1790943470
Name:ISABELLA PIEDRA PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:ISABELLA PIEDRA PROFESSIONAL DENTAL CORPORATION
Other - Org Name:CHILDREN'S DENTISTRY OF RANCHO CUCAMONGA
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ISABELLA
Authorized Official - Middle Name:
Authorized Official - Last Name:PIEDRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-483-6851
Mailing Address - Street 1:9469 HAVEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5305
Mailing Address - Country:US
Mailing Address - Phone:909-483-6851
Mailing Address - Fax:909-483-6853
Practice Address - Street 1:9469 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5305
Practice Address - Country:US
Practice Address - Phone:909-483-6851
Practice Address - Fax:909-483-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA473071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA47307OtherDENTAL LICENCE