Provider Demographics
NPI:1245366020
Name:KUSUMO-RAHARDJO, TJAHJADI (DDS)
Entity type:Individual
Prefix:
First Name:TJAHJADI
Middle Name:
Last Name:KUSUMO-RAHARDJO
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 1:222 S EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-2525
Mailing Address - Country:US
Mailing Address - Phone:949-769-0495
Mailing Address - Fax:714-400-2085
Practice Address - Street 1:222 S EMERALD ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-2525
Practice Address - Country:US
Practice Address - Phone:949-769-0495
Practice Address - Fax:714-400-2085
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49917OtherDENTIST