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General NPI Number Information
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NPI Number | 1033596788
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Entity Type | Organization
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Legal Business Name | PETER SUMARSONO PROFESSIONAL DENTAL CORPORATION
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Dates
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Enumeration Date | 05/01/2015
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Last Update Date | 05/01/2015
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Provider Practice Location Address
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Address Line | 9110 ADAMS AVENUE
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92646
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Country | US
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Telephone | 714-968-4487
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Fax | 714-968-1146
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Provider Business Mailing Address
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Address Line | 18543 YORBA LINDA BLVD. #250
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City | YORBA LINDA
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State | CA
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Zip | 92886
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | PETER ROBERTSON SUMARSONO
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Credential | DDS
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Telephone | 714-864-8261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 40736
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License Number State | CA
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