Homer Gary Ketcherside, D.D.S.,M.S.

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

28872 Issued in CA

Practice address

720 Magnolia Ave
Suite A1
Corona, CA 92879-3119

Phone

(951) 737-3800

Fax

(951) 737-3937

NPI assigned

May 17, 2012

Last updated

Jul 22, 2013By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Master of Science

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Ketcherside Dental Corporation

  dba Brace Connection

  • Orthodontics and Dentofacial Orthopedics Dentistry
  • Corona, CA
  • NPI 1629557517
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1337212800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1374451200000",
    "number": "1043570658",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "720 MAGNOLIA AVE",
            "address_2": "SUITE A1",
            "city": "CORONA",
            "state": "CA",
            "postal_code": "928793119",
            "telephone_number": "951-737-3802",
            "fax_number": "951-737-3937"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "720 MAGNOLIA AVE",
            "address_2": "SUITE A1",
            "city": "CORONA",
            "state": "CA",
            "postal_code": "928793119",
            "telephone_number": "951-737-3800",
            "fax_number": "951-737-3937"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KETCHERSIDE",
        "first_name": "HOMER",
        "middle_name": "GARY",
        "credential": "D.D.S.,M.S.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2012-05-17",
        "last_updated": "2013-07-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "28872",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Rachel Kennedy
• Khaled Keriz
• Keshav RX, Inc. (6th Street Pharmacy)
• Keshav RX, Inc. (6th Street Pharmacy)
• Ketcherside Dental Corporation (Brace Connection)
• Keys to Tranquility- Iop and PHP Program Inc (Keys to Tranquility- IOP and PHP)
• KFK Corp (Care-More Pharmacy)
• Albert Khait, M.D,.
• Aliuddin M Khaja, MD
• Maie Gamal Fathalla Khalaf, RPH

• Orthodontics and Dentofacial Orthopedics Dentistry in Corona, CA
• Providers in Corona, CA by specialty
• Orthodontics and Dentofacial Orthopedics Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.