Provider Demographics
NPI:1720471055
Name:JS LID DDS, INC.
Entity Type:Organization
Organization Name:JS LID DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:
Authorized Official - Last Name:LID
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:676-320-3611
Mailing Address - Street 1:9791 BASELINE RD.
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-987-8779
Mailing Address - Fax:909-987-2815
Practice Address - Street 1:9791 BASELINE RD.
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-987-8779
Practice Address - Fax:909-987-2815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty