Provider Demographics
NPI:1669893731
Name:HARSONO, MASLY (DDS, MS, DMD)
Entity type:Individual
Prefix:DR
First Name:MASLY
Middle Name:
Last Name:HARSONO
Suffix:
Gender:M
Credentials:DDS, MS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 MONTEREY AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-5319
Mailing Address - Country:US
Mailing Address - Phone:408-354-1717
Mailing Address - Fax:408-395-7664
Practice Address - Street 1:431 MONTEREY AVE STE 6
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-5319
Practice Address - Country:US
Practice Address - Phone:408-354-1717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA649771223G0001X
MADN18554661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice