Provider Demographics
NPI:1568617587
Name:SUMARSONO, PETER ROBERTSON (DDS)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:ROBERTSON
Last Name:SUMARSONO
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 1:17092 VISTA MORAGA
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-6209
Mailing Address - Country:US
Mailing Address - Phone:714-864-8261
Mailing Address - Fax:714-572-0572
Practice Address - Street 1:62 CORPORATE PARK
Practice Address - Street 2:BARRANCA MEDICAL PLAZA, SUITE 200
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606
Practice Address - Country:US
Practice Address - Phone:714-864-8261
Practice Address - Fax:714-572-0572
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice