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General NPI Number Information
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NPI Number | 1518749050
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Entity Type | Individual
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Provider Name | JESSICA SUHARDJO DMD, MS
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Gender | Female
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Dates
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Enumeration Date | 10/18/2023
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Last Update Date | 10/18/2023
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Provider Practice Location Address
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Address Line | 15290 BEAR VALLEY RD STE B
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City | VICTORVILLE
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State | CA
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Zip | 92395-8515
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Country | US
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Telephone | 760-493-3215
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Fax |
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Provider Business Mailing Address
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Address Line | 2167 N 1ST AVE
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City | UPLAND
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State | CA
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Zip | 91784-1446
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Country | US
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Telephone | 909-331-8445
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DDS108563
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License Number State | CA
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