Provider Demographics
NPI:1902003593
Name:JEFFERSON AND CHOKKA DENTAL CORPORATION
Entity Type:Organization
Organization Name:JEFFERSON AND CHOKKA DENTAL CORPORATION
Other - Org Name:SIERRA LAKES DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-357-0869
Mailing Address - Street 1:2860 MICHELLE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-1009
Mailing Address - Country:US
Mailing Address - Phone:714-508-3600
Mailing Address - Fax:714-368-2092
Practice Address - Street 1:16475 SIERRA LAKES PARKWAY
Practice Address - Street 2:SUITE 140
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336
Practice Address - Country:US
Practice Address - Phone:909-357-0869
Practice Address - Fax:909-357-4887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty