Healthcare Provider Details

I. General information

NPI: 1164139002
Provider Name (Legal Business Name): ANDREW GEOFFREY WIDDIFIELD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 TWEEDY BLVD
SOUTH GATE CA
90280-6304
US

IV. Provider business mailing address

7521 EDINGER AVE UNIT 4601
HUNTINGTON BEACH CA
92647-0614
US

V. Phone/Fax

Practice location:
  • Phone: 323-564-2444
  • Fax:
Mailing address:
  • Phone: 401-595-1298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number108329
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: