Provider Demographics
NPI:1609061720
Name:SUSANTO DENTAL CORPORATION
Entity Type:Organization
Organization Name:SUSANTO DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:SUSANTO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-401-0747
Mailing Address - Street 1:10226 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:TEMPLE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91780-3346
Mailing Address - Country:US
Mailing Address - Phone:626-401-0747
Mailing Address - Fax:626-401-0844
Practice Address - Street 1:1240 N HACIENDA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-1663
Practice Address - Country:US
Practice Address - Phone:626-931-2525
Practice Address - Fax:626-931-2527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty