MEDICARE: DR. PATRICIA HADIWIDJAJA GUSTI DDS

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	60534	CA

General Provider Information

NPI Number	:	1740578467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PATRICIA HADIWIDJAJA GUSTI DDS

Provider Business Mailing Address
First Line	:	10256 LOTUS CT
Second Line	:
City	:	STANTON
State	:	CA
Zip	:	90680-8506
Country	:	US
Telephone Number	:	714-244-7424
Fax Number	:

Provider Business Practice Location Address
First Line	:	1012 E BASTANCHURY RD
Second Line	:
City	:	FULLERTON
State	:	CA
Zip	:	92835-2782
Country	:	US
Telephone Number	:	714-257-1220
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	01/17/2024

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