Provider Demographics
NPI:1740949056
Name:WIREDJA, DAMITA DORA (DDA)
Entity type:Individual
Prefix:DR
First Name:DAMITA
Middle Name:DORA
Last Name:WIREDJA
Suffix:
Gender:F
Credentials:DDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 ATLANTIC BLVD STE I
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-3184
Mailing Address - Country:US
Mailing Address - Phone:323-771-7551
Mailing Address - Fax:323-771-7881
Practice Address - Street 1:6100 ATLANTIC BLVD STE I
Practice Address - Street 2:
Practice Address - City:MAYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90270-3184
Practice Address - Country:US
Practice Address - Phone:323-771-7551
Practice Address - Fax:323-771-7881
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS106565122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADDS106565OtherPRIVATE