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General NPI Number Information
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NPI Number | 1295830487
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Entity Type | Organization
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Legal Business Name | AGUNG PRIBADI DDS INC
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 05/22/2013
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Provider Practice Location Address
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Address Line | 600 E WHITTIER BLVD
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City | LA HABRA
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State | CA
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Zip | 90631
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Country | US
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Telephone | 562-691-3070
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Fax | 562-691-7198
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Provider Business Mailing Address
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Address Line | 600 E WHITTIER BLVD
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City | LA HABRA
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State | CA
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Zip | 90631
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Country | US
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Telephone | 562-691-3070
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Fax | 562-691-7198
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Authorized Official
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Title or Position | CEO
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Name | AGUNG PRIBADI
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Credential | DDS
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Telephone | 562-691-3070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 45519
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License Number State | CA
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