Provider Demographics
NPI:1184999815
Name:PERSONA DENTAL GROUP OF SHAW DDS, INC.
Entity type:Organization
Organization Name:PERSONA DENTAL GROUP OF SHAW DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:CHUNG
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-347-6172
Mailing Address - Street 1:8221 ROCHESTER AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-0721
Mailing Address - Country:US
Mailing Address - Phone:310-347-6172
Mailing Address - Fax:
Practice Address - Street 1:8221 ROCHESTER AVE STE 110
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-0721
Practice Address - Country:US
Practice Address - Phone:310-347-6172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA594551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty