MEDICARE: LYDIA KOERNIANINGSIH DDS A PROF CORP

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	122300000X	Dentist	48488	CA

General Provider Information

NPI Number	:	1922349521
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LYDIA KOERNIANINGSIH DDS A PROF CORP

Provider Business Mailing Address
First Line	:	1125 E 17TH ST STE W234
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2228
Country	:	US
Telephone Number	:	714-558-4895
Fax Number	:	714-558-4896

Provider Business Practice Location Address
First Line	:	1125 E 17TH ST STE W234
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-2228
Country	:	US
Telephone Number	:	714-558-4895
Fax Number	:	714-558-4896

Authorized Official
Title or Position	:	DENTIST / OWNER
Name	:	LYDIA KOERNIANINGSIH
Credential	:
Telephone Number	:	714-558-4895

Provider Enumeration Date	:	03/06/2013
Last Update Date	:	01/24/2020

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