Provider Demographics
NPI:1851664601
Name:SULAEMAN, INDHIRA AUDREY H (DDS)
Entity Type:Individual
Prefix:
First Name:INDHIRA AUDREY
Middle Name:H
Last Name:SULAEMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:INDHIRA
Other - Middle Name:HADISUBROTO
Other - Last Name:SULAEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:25054 BASE LINE ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-4026
Mailing Address - Country:US
Mailing Address - Phone:909-889-9591
Mailing Address - Fax:909-889-8721
Practice Address - Street 1:25054 BASE LINE ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-4026
Practice Address - Country:US
Practice Address - Phone:909-889-9591
Practice Address - Fax:909-889-8721
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA365491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice