Provider Demographics
NPI:1366469017
Name:MUDITAJAYA, WINSTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:WINSTON
Middle Name:
Last Name:MUDITAJAYA
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 1:9123 SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4522
Mailing Address - Country:US
Mailing Address - Phone:562-949-0177
Mailing Address - Fax:562-949-4776
Practice Address - Street 1:9123 SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4522
Practice Address - Country:US
Practice Address - Phone:562-949-0177
Practice Address - Fax:562-949-4776
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice