Provider Demographics
NPI:1598811481
Name:REKSOATMODJO, MURIJONO (DDS)
Entity Type:Individual
Prefix:
First Name:MURIJONO
Middle Name:
Last Name:REKSOATMODJO
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 1:6230 GUSHEE ST
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:CA
Mailing Address - Zip Code:95018-9129
Mailing Address - Country:US
Mailing Address - Phone:831-335-5324
Mailing Address - Fax:831-335-5928
Practice Address - Street 1:6230 GUSHEE ST
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:CA
Practice Address - Zip Code:95018-9129
Practice Address - Country:US
Practice Address - Phone:831-335-5324
Practice Address - Fax:831-335-5928
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS 368251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice