Provider Demographics
NPI:1245589282
Name:WIDODO & LEE DDS A PROFESSIONAL DENTAL CORP
Entity Type:Organization
Organization Name:WIDODO & LEE DDS A PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDODO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-590-5600
Mailing Address - Street 1:2112 S GAREY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766
Mailing Address - Country:US
Mailing Address - Phone:909-590-5600
Mailing Address - Fax:909-590-5606
Practice Address - Street 1:2112 S GAREY AVE STE A
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766
Practice Address - Country:US
Practice Address - Phone:909-590-5600
Practice Address - Fax:909-590-5606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46152261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental