Provider Demographics
NPI:1598803801
Name:REDJO - SETYONO, MELLISRI (DDS)
Entity Type:Individual
Prefix:
First Name:MELLISRI
Middle Name:
Last Name:REDJO - SETYONO
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 1:749 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-2115
Mailing Address - Country:US
Mailing Address - Phone:213-483-5616
Mailing Address - Fax:
Practice Address - Street 1:749 S UNION AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-2115
Practice Address - Country:US
Practice Address - Phone:213-483-5616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA364191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice