Provider Demographics
NPI:1477622165
Name:MAVERN SUPRONO DDS INC
Entity type:Organization
Organization Name:MAVERN SUPRONO DDS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MAVERN
Authorized Official - Middle Name:S
Authorized Official - Last Name:SUPRONO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-783-9099
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-783-9099
Mailing Address - Fax:909-824-1677
Practice Address - Street 1:1080 E WASHINGTON ST
Practice Address - Street 2:SUITE B
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-783-9099
Practice Address - Fax:909-824-1677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty