Provider Demographics
NPI:1225588254
Name:HARSONO DENTAL CORP
Entity Type:Organization
Organization Name:HARSONO DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MASLY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARSONO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:646-338-7593
Mailing Address - Street 1:550 MORELAND WAY
Mailing Address - Street 2:4512
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95054-4123
Mailing Address - Country:US
Mailing Address - Phone:650-667-1369
Mailing Address - Fax:650-396-2959
Practice Address - Street 1:431 MONTEREY AVE STE 6
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5319
Practice Address - Country:US
Practice Address - Phone:408-354-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA649771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty