Dental Board of California
Licensing details for: 20243
Name: Grand Terrace Modern Dentistry, Dental Group of Grand Terrace Modern Dentistry, Inc.
License Type: Fictitious Name Permit
Primary Status: Current - Active
Organization Classification: Corporation
Address of Record
22471 Barton Rd
GRAND TERRACE CA 92313
Map
License Relationships
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: WALTERS, CHRISTOPHER ROBIN
License/Registration Type: Dentist License
License Number: 104123 Primary Status: Current - Active
Address :
22471 Barton Rd
GRAND TERRACE CA 92313-5008
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: DHAMA, DEEPIKA S
License/Registration Type: Dentist License
License Number: 49044 Primary Status: Current - Active
Address :
2044 California Ave
CORONA CA 92881-3300
RIVERSIDE COUNTY
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: POULSEN, KYLE DOUGLASS
License/Registration Type: Dentist License
License Number: 64955 Primary Status: Current - Active
Address :
32891 Western Hills Dr
Ste 103
WINCHESTER CA 92596
RIVERSIDE COUNTY
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: MERCER, JUSTIN WILLIAM
License/Registration Type: Dentist License
License Number: 59375 Primary Status: Current - Active
Address :
3150 Case Rd Bldg C
PERRIS CA 92570-5552
RIVERSIDE COUNTY
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: ZAKLAMA, KARIM MAGID
License/Registration Type: Dentist License
License Number: 61349 Primary Status: Current - Active
Address :
2700 E Workman Ave
WEST COVINA CA 91791-6625
LOS ANGELES COUNTY
