Provider Demographics
NPI:1063432946
Name:CHETTY, CHETHAN (DDS)
Entity type:Individual
Prefix:DR
First Name:CHETHAN
Middle Name:
Last Name:CHETTY
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 1:2525 COLORADO BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1062
Mailing Address - Country:US
Mailing Address - Phone:323-258-2885
Mailing Address - Fax:323-258-8004
Practice Address - Street 1:2525 COLORADO BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1062
Practice Address - Country:US
Practice Address - Phone:323-258-2885
Practice Address - Fax:323-258-8004
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA482461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice