MEDICARE: PARK AVENUE FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	34127	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205019858
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PARK AVENUE FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	1087 N PARK AVE
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91768-3026
Country	:	US
Telephone Number	:	909-629-0201
Fax Number	:

Provider Business Practice Location Address
First Line	:	1087 N PARK AVE
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91768-3026
Country	:	US
Telephone Number	:	909-629-0201
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. SOEDHARSONO JUDO
Credential	:	D.D.S.
Telephone Number	:	909-629-0201

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	12/06/2007

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Directions to “PARK AVENUE FAMILY DENTISTRY ” Practice Location

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