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General NPI Number Information
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NPI Number | 1194152736
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Entity Type | Individual
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Provider Name | ERLINE DIONA POERWANTO D.D.S
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Gender | Female
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Dates
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Enumeration Date | 09/27/2013
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Last Update Date | 09/27/2013
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Provider Practice Location Address
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Address Line | 2155 WEBSTER STREET
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City | SAN FRANCISCO
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State | CA
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Zip | 94115
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Country | US
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Telephone | 209-910-3505
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 7194
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City | STOCKTON
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State | CA
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Zip | 95267-0194
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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 |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 62687
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 62687
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License Number State | CA
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