Provider Demographics
NPI:1316351794
Name:SUPRIYA D MHASKAR A DENTAL CORP
Entity type:Organization
Organization Name:SUPRIYA D MHASKAR A DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUPRIYA
Authorized Official - Middle Name:DHANANJAYA
Authorized Official - Last Name:MHASKAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-465-5551
Mailing Address - Street 1:5436 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4206
Mailing Address - Country:US
Mailing Address - Phone:909-465-5551
Mailing Address - Fax:909-465-5191
Practice Address - Street 1:5436 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710
Practice Address - Country:US
Practice Address - Phone:909-465-5551
Practice Address - Fax:909-465-5191
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SUPRIYA D MHASKAR, A DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-06-13
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40278122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40278-01OtherDENTI-CAL