Provider Demographics
NPI:1811037443
Name:SUDIRGO, RIDWAN (DDS)
Entity type:Individual
Prefix:DR
First Name:RIDWAN
Middle Name:
Last Name:SUDIRGO
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:PO BOX 3066
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-8366
Mailing Address - Country:US
Mailing Address - Phone:323-721-6221
Mailing Address - Fax:323-721-8641
Practice Address - Street 1:2218 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2302
Practice Address - Country:US
Practice Address - Phone:323-721-6221
Practice Address - Fax:323-721-8641
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA360101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB 36010-01Medicaid