Provider Demographics
NPI:1205489671
Name:ADIPUTRA, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:ADIPUTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 W KIRBY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-7208
Mailing Address - Country:US
Mailing Address - Phone:217-398-9898
Mailing Address - Fax:
Practice Address - Street 1:314 W KIRBY AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7208
Practice Address - Country:US
Practice Address - Phone:217-398-9898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019032270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist