Provider Demographics
NPI:1205982311
Name:JUSTIN, HARTANTO LAWRENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:HARTANTO
Middle Name:LAWRENCE
Last Name:JUSTIN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 NORTH BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031
Mailing Address - Country:US
Mailing Address - Phone:323-221-6090
Mailing Address - Fax:
Practice Address - Street 1:3231 N BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2801
Practice Address - Country:US
Practice Address - Phone:323-221-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice