Provider Demographics
NPI:1508876277
Name:SUTANTO, YENI (DDS)
Entity Type:Individual
Prefix:DR
First Name:YENI
Middle Name:
Last Name:SUTANTO
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 1:6931 VAN NUYS BLVD
Mailing Address - Street 2:SUITE, #100
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-3937
Mailing Address - Country:US
Mailing Address - Phone:818-988-8080
Mailing Address - Fax:818-988-8168
Practice Address - Street 1:6931 VAN NUYS BLVD
Practice Address - Street 2:SUITE, #100
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-3937
Practice Address - Country:US
Practice Address - Phone:818-988-8080
Practice Address - Fax:818-988-8168
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice