Provider Demographics
NPI:1962743138
Name:MAK, KAREN (DDS)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:MAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12455 VICTORIA GARDENS LN STE 190
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-7534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12455 VICTORIA GARDENS LN STE 190
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-7534
Practice Address - Country:US
Practice Address - Phone:909-463-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-12
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE605300971223P0221X
CA1010221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry