Provider Demographics
NPI:1083700967
Name:PUTRASAHAN, RAHADIAN KRIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAHADIAN
Middle Name:KRIS
Last Name:PUTRASAHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7650 S MCCLINTOCK DR
Mailing Address - Street 2:SUITE 103-235
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1672
Mailing Address - Country:US
Mailing Address - Phone:480-788-3627
Mailing Address - Fax:
Practice Address - Street 1:3195 W RAY RD
Practice Address - Street 2:SUITE #3
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-2417
Practice Address - Country:US
Practice Address - Phone:480-788-3627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ46951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice