Provider Demographics
NPI:1104185792
Name:HERMAWAN TJIOE DDS INC
Entity Type:Organization
Organization Name:HERMAWAN TJIOE DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERMAWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:TJIOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-725-1111
Mailing Address - Street 1:1313 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-1766
Mailing Address - Country:US
Mailing Address - Phone:661-725-1111
Mailing Address - Fax:
Practice Address - Street 1:1313 MAIN ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1766
Practice Address - Country:US
Practice Address - Phone:661-725-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39900261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental