| NPI | 1184972135 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | ANDRE WIDODO Owner 909-670-1100 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist, General Practice |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: CA 46152) |
| Enumeration Date | 2012-08-23 |
| Last Update Date | 2022-05-11 |