Provider Demographics
NPI:1649338948
Name:SURYA, METTA (DDS)
Entity type:Individual
Prefix:
First Name:METTA
Middle Name:
Last Name:SURYA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 N RIVERSIDE AVE
Mailing Address - Street 2:#3
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-8058
Mailing Address - Country:US
Mailing Address - Phone:909-875-1279
Mailing Address - Fax:909-875-1592
Practice Address - Street 1:1734 N RIVERSIDE AVE
Practice Address - Street 2:#3
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-8058
Practice Address - Country:US
Practice Address - Phone:909-875-1279
Practice Address - Fax:909-875-1592
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA498081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG 93879 01OtherMEDI-CAL