MEDICARE: P PUTRASAHAN DDS INC

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	39466	CA

General Provider Information

NPI Number	:	1831386168
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	P PUTRASAHAN DDS INC

Provider Business Mailing Address
First Line	:	68905 VISTA CHINO
Second Line	:
City	:	CATHEDRAL CITY
State	:	CA
Zip	:	92234-4866
Country	:	US
Telephone Number	:	760-325-2503
Fax Number	:

Provider Business Practice Location Address
First Line	:	68905 VISTA CHINO
Second Line	:
City	:	CATHEDRAL CITY
State	:	CA
Zip	:	92234-4866
Country	:	US
Telephone Number	:	760-325-2503
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PERRI SOFIAN PUTRASAHAN
Credential	:	DDS
Telephone Number	:	760-325-2503

Provider Enumeration Date	:	10/01/2007
Last Update Date	:	12/26/2013

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