Provider Demographics
NPI:1508901257
Name:WIDODO, ANDRE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:
Last Name:WIDODO
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 1:2112 S GAREY AVE STE A
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-5600
Mailing Address - Country:US
Mailing Address - Phone:909-590-5600
Mailing Address - Fax:909-590-5606
Practice Address - Street 1:2112 S GAREY AVE STE A
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-5600
Practice Address - Country:US
Practice Address - Phone:909-590-5600
Practice Address - Fax:909-590-5606
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA461521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1184972135OtherDENTIST