Provider Demographics
NPI:1508296450
Name:Y.A.SATYARAHARDJA DDS.INC.
Entity Type:Organization
Organization Name:Y.A.SATYARAHARDJA DDS.INC.
Other - Org Name:CITRUS GROVE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YINTAWATI
Authorized Official - Middle Name:
Authorized Official - Last Name:SATYARAHARDJA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-966-0300
Mailing Address - Street 1:2520 E WORKMAN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1534
Mailing Address - Country:US
Mailing Address - Phone:626-966-0300
Mailing Address - Fax:696-966-0336
Practice Address - Street 1:2520 E WORKMAN AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1534
Practice Address - Country:US
Practice Address - Phone:626-966-0300
Practice Address - Fax:696-966-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46955122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty