Provider Demographics
NPI:1922349521
Name:LYDIA KOERNIANINGSIH DDS A PROF CORP
Entity Type:Organization
Organization Name:LYDIA KOERNIANINGSIH DDS A PROF CORP
Other - Org Name:LDJ FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOERNIANINGSIH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-558-4895
Mailing Address - Street 1:1125 E 17TH ST STE W234
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2228
Mailing Address - Country:US
Mailing Address - Phone:714-558-4895
Mailing Address - Fax:714-558-4896
Practice Address - Street 1:1125 E 17TH ST STE W234
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2228
Practice Address - Country:US
Practice Address - Phone:714-558-4895
Practice Address - Fax:714-558-4896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-06
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48488122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty