Healthcare Provider Details

I. General information

NPI: 1184972135
Provider Name (Legal Business Name): LEE & WIDODO DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2012
Last Update Date: 05/11/2022
Certification Date: 05/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5562 PHILADELPHIA ST STE 103
CHINO CA
91710
US

IV. Provider business mailing address

5562 PHILADELPHIA ST STE 103
CHINO CA
91710
US

V. Phone/Fax

Practice location:
  • Phone: 909-670-1100
  • Fax: 909-398-0026
Mailing address:
  • Phone: 909-670-1100
  • Fax: 909-398-0026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number46152
License Number StateCA

VIII. Authorized Official

Name: ANDRE WIDODO
Title or Position: OWNER
Credential: DDS
Phone: 909-670-1100