Provider Demographics
NPI:1699842492
Name:ETEMADI DENTAL CORPORATION
Entity type:Organization
Organization Name:ETEMADI DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHASHAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:ETEMADI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-899-8757
Mailing Address - Street 1:12729 FOOTHILL BLVD
Mailing Address - Street 2:SUITE # A
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-9334
Mailing Address - Country:US
Mailing Address - Phone:909-899-8757
Mailing Address - Fax:909-899-8760
Practice Address - Street 1:12729 FOOTHILL BLVD
Practice Address - Street 2:SUITE # A
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9334
Practice Address - Country:US
Practice Address - Phone:909-899-8757
Practice Address - Fax:909-899-8760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9124301OtherMEDICAL
CA868675OtherUNITED CONCORDIA
CA868675OtherUNITED CONCORDIA