Provider Demographics
NPI:1447583661
Name:ANDRE WIDODO DDS A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ANDRE WIDODO DDS A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST / 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:626-444-7645
Mailing Address - Street 1:11635 VALLEY BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-3071
Mailing Address - Country:US
Mailing Address - Phone:626-444-7645
Mailing Address - Fax:626-444-7628
Practice Address - Street 1:11635 VALLEY BLVD STE E
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3071
Practice Address - Country:US
Practice Address - Phone:626-444-7645
Practice Address - Fax:626-444-7628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-08
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46152261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherDENTAL OFFICE