| NPI | 1205373891 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MELISA TIRTAPUTRA SUSANTO D.D.S, M.S. 626-241-2669 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: WA DE 60481607) |
| Enumeration Date | 2017-01-20 |
| Last Update Date | 2017-01-20 |