Provider Demographics
NPI:1023239944
Name:SUPRONO, MAVERN (DDS)
Entity type:Individual
Prefix:MR
First Name:MAVERN
Middle Name:
Last Name:SUPRONO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-783-9099
Mailing Address - Fax:
Practice Address - Street 1:1080 E WASHINGTON
Practice Address - Street 2:B
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-783-9099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist