=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225588254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARSONO DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2016
-----------------------------------------------------
Last Update Date | 12/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 MONTEREY AVE STE 6
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95030-5319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-354-1717
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 431 MONTEREY AVE STE 6
-----------------------------------------------------
City | LOS GATOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95030-5319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-354-1717
-----------------------------------------------------
Fax | 408-395-7664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MASLY HARSONO
-----------------------------------------------------
Credential | DMD, MS
-----------------------------------------------------
Telephone | 646-338-7593
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 64977
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------