Provider Demographics
NPI:1659438133
Name:TIONOWIDJAJA, ENTY (DDS)
Entity Type:Individual
Prefix:
First Name:ENTY
Middle Name:
Last Name:TIONOWIDJAJA
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 1:721 W. WHITTIER BLVD.
Mailing Address - Street 2:SUITE 'E'
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-3772
Mailing Address - Country:US
Mailing Address - Phone:562-691-3688
Mailing Address - Fax:
Practice Address - Street 1:721 W. WHITTIER BLVD.
Practice Address - Street 2:SUITE 'E'
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-3772
Practice Address - Country:US
Practice Address - Phone:562-691-3688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA371701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice