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General NPI Number Information
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NPI Number | 1942603105
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Entity Type | Organization
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Legal Business Name | K.SUMARDI DDS INC.
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Dates
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Enumeration Date | 10/02/2014
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Last Update Date | 10/02/2014
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Provider Practice Location Address
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Address Line | 1965 FOOTHILL BLVD STE L
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City | LA VERNE
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State | CA
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Zip | 91750-3502
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Country | US
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Telephone | 909-596-6500
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Fax | 909-596-8809
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Provider Business Mailing Address
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Address Line | 1965 FOOTHILL BLVD STE L
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City | LA VERNE
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State | CA
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Zip | 91750-3502
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Country | US
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Telephone | 909-596-6500
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Fax | 909-596-8809
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KUSUMO SUMARDI
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Credential |
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Telephone | 909-596-6500
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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 | 41680
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License Number State | CA
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