Provider Demographics
NPI:1710265251
Name:LUWIHARTO, SHEILA M TEDJA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:SHEILA
Middle Name:M TEDJA
Last Name:LUWIHARTO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:MATILDA
Other - Last Name:TEDJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:27001 LA PAZ RD STE 236
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5537
Mailing Address - Country:US
Mailing Address - Phone:949-768-0211
Mailing Address - Fax:
Practice Address - Street 1:27001 LA PAZ RD STE 236
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5537
Practice Address - Country:US
Practice Address - Phone:949-768-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA601391223G0001X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice