Provider Demographics
NPI:1275695553
Name:SATYARAHARDJA, YINTAWATI A (DDS)
Entity Type:Individual
Prefix:DR
First Name:YINTAWATI
Middle Name:A
Last Name:SATYARAHARDJA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 S LARK ELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3841
Mailing Address - Country:US
Mailing Address - Phone:626-893-5677
Mailing Address - Fax:
Practice Address - Street 1:1199 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3507
Practice Address - Country:US
Practice Address - Phone:909-381-6507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist