Dental Board of California
Licensing details for: 15533
Name: PACKING HOUSE DENTAL AND ORTHODONTICS DENTAL PRACTICE OF KETCHERSIDE DENTAL CORPORATION
License Type: Fictitious Name Permit
Primary Status: Current - Active
Organization Classification: Corporation
License Relationships
FNP Owners
License/Registration Role: Fictitious Name Permit
Related Party Role: Owners
Name: KETCHERSIDE, HOMER GARY
Address Not Disclosed
FNP to DDS or OMS
License/Registration Role: Fictitious Name Permit
Related Party Role: Must hold an active Dental License, or Oral Maxillofacial Surgery Permit
Name: KETCHERSIDE, HOMER GARY
License/Registration Type: Dentist License
License Number: 28872 Primary Status: Current - Active
Address :
400 W Stuart AVe
ste.110
REDLANDS CA 92374
SAN BERNARDINO COUNTY
