Provider Demographics
NPI:1912441148
Name:SUDAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:SUDAN DENTAL CORPORATION
Other - Org Name:CHINO DENTAL ARTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SUDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-536-1900
Mailing Address - Street 1:4110 EDISON AVE
Mailing Address - Street 2:107-B
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-8409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4110 EDISON AVE
Practice Address - Street 2:107-B
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-8409
Practice Address - Country:US
Practice Address - Phone:909-536-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty