| NPI | 1255721254 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TJAHJADI ANDY KUSUMO President 949-769-0495 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: CA 49917) |
| Enumeration Date | 2015-01-28 |
| Last Update Date | 2015-01-28 |