Provider Demographics
NPI:1942381066
Name:MUDITAJAYA DENTAL CORPORATION
Entity Type:Organization
Organization Name:MUDITAJAYA DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANNY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUDITAJAYA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-949-0177
Mailing Address - Street 1:9123 SLAUSON AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4522
Mailing Address - Country:US
Mailing Address - Phone:562-949-0177
Mailing Address - Fax:562-949-4776
Practice Address - Street 1:9123 SLAUSON AVE
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4522
Practice Address - Country:US
Practice Address - Phone:562-949-0177
Practice Address - Fax:562-949-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9166001Medicaid