Provider Demographics
NPI:1821212010
Name:FAMILY DENTISTRY AT TURNER PLAZA
Entity Type:Organization
Organization Name:FAMILY DENTISTRY AT TURNER PLAZA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISHAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MITTAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-987-5522
Mailing Address - Street 1:10064 ARROW RTE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4194
Mailing Address - Country:US
Mailing Address - Phone:909-987-5522
Mailing Address - Fax:909-987-5532
Practice Address - Street 1:10064 ARROW RTE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4194
Practice Address - Country:US
Practice Address - Phone:909-987-5522
Practice Address - Fax:909-987-5532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41760122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92877Medicaid