Ketcherside Dental Corporation

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

License

28872 Issued in CA

Legal business name

KETCHERSIDE DENTAL CORPORATION

Doing business as

Brace Connection
Gary Ketcherside Orthodontics INC
Packing House District Dental & Orthodontics

Practice address

720 Magnolia Ave Ste A1
Corona, CA 92879-3119

Phone

(951) 737-3800

Fax

(951) 737-3937

NPI assigned

Aug 10, 2018

Last updated

May 11, 2020By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Homer Ketcherside, DDSNPI 1043570658

Title

President

Phone

(909) 810-7167

Specialties & licenses 1

Addresses

Other names 3

• Brace Connection Doing business as
• Gary Ketcherside Orthodontics INC Doing business as
• Packing House District Dental & Orthodontics Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Homer Gary Ketcherside, D.D.S.,M.S.

  • Orthodontics and Dentofacial Orthopedics Dentistry
  • Corona, CA
  • NPI 1043570658
  NPD (past) Authorized official

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

{
    "created_epoch": "1533859200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1589155200000",
    "number": "1629557517",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "400 W STUART AVE STE 110",
            "city": "REDLANDS",
            "state": "CA",
            "postal_code": "923743129",
            "telephone_number": "909-793-1595"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "720 MAGNOLIA AVE STE A1",
            "city": "CORONA",
            "state": "CA",
            "postal_code": "928793119",
            "telephone_number": "951-737-3800",
            "fax_number": "951-737-3937"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "1468 Industrial Park Ave",
            "address_purpose": "LOCATION",
            "city": "Redlands",
            "state": "CA",
            "postal_code": "923742892",
            "country_code": "US",
            "telephone_number": "909-793-1595",
            "fax_number": "909-307-2154",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "400 W Stuart Ave Ste 110",
            "address_purpose": "LOCATION",
            "city": "Redlands",
            "state": "CA",
            "postal_code": "923743129",
            "country_code": "US",
            "telephone_number": "909-793-1595",
            "fax_number": "909-307-2154",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "KETCHERSIDE DENTAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-08-10",
        "last_updated": "2020-05-11",
        "certification_date": "2020-05-11",
        "status": "A",
        "authorized_official_last_name": "KETCHERSIDE",
        "authorized_official_first_name": "HOMER",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "909-810-7167",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": "CA",
            "license": "28872",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Brace Connection",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Gary Ketcherside Orthodontics INC",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Packing House District Dental & Orthodontics",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Jason Kendall
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• Homer Gary Ketcherside, D.D.S.,M.S.
• 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

• 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 May 11, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.