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General NPI Number Information
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NPI Number | 1699895383
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Entity Type | Organization
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Legal Business Name | WINSTON MUDITAJAYA, D.D.S., INC.
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 17550 BLOOMFIELD AVE SUITE C
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City | CERRITOS
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State | CA
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Zip | 90703-8584
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Country | US
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Telephone | 562-809-4464
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Fax |
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Provider Business Mailing Address
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Address Line | 17550 BLOOMFIELD AVE SUITE C
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City | CERRITOS
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State | CA
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Zip | 90703-8584
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Country | US
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Telephone | 562-809-4464
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. WINSTON MUDITAJAYA
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Credential | DDS
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Telephone | 562-809-4464
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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 | 44515
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License Number State | CA
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