Provider Demographics
NPI:1942603105
Name:K.SUMARDI DDS INC.
Entity Type:Organization
Organization Name:K.SUMARDI DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KUSUMO
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMARDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-596-6500
Mailing Address - Street 1:1965 FOOTHILL BLVD STE L
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3502
Mailing Address - Country:US
Mailing Address - Phone:909-596-6500
Mailing Address - Fax:909-596-8809
Practice Address - Street 1:1965 FOOTHILL BLVD STE L
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3502
Practice Address - Country:US
Practice Address - Phone:909-596-6500
Practice Address - Fax:909-596-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty